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 be deemed by health professionals to be mentally ill or suffering 
from dementia, it is difficult to determine whether this is in fact the case. The 
Central Australian Advocacy Service (CAAS) contended that the tests developed to 
assess dementia are inappropriate for Aboriginal people. In addition to practical
 difficulties in assessing dementia, it was suggested that most of the Aboriginal
 people in nursing homes exhibit symptoms of confusion and distress similar to dementia: 

Many residents have been genuinely, justifiably confused and fearful about their 
whereabouts and their future. Some residents of nursing homes have told us that, 
after years had passed, they were still in hospital waiting to go home. Other 
residents have, in the words of relatives, 'talked silly' during visits — 
including forgetting that certain relatives have passed away and must not be
 named. When away from the [nursing home], in the company of family and their country, 
however, these same residents have been clear headed and lucid... This is an indication
 of the anxiety which people are experiencing at separation from their own kin and country.57 

Many Aboriginal people living in nursing homes are unaware of their rights as 
patients. Their powerlessness is compounded by the fact that most staff in the 
homes are non-Aboriginal and do not speak Aboriginal languages. 

As people get older they tend to revert to their first language. This has sometimes 
been interpreted as a sign of dementia. Becoming non-communicative and withdrawn due to 

Page 704 Mental Illness Inquiry 

depression has also been interpreted as dementia. Of course once old people are
 diagnosed as demented, they can have guardians appointed, with resultant loss of rights.58 

Many Aboriginal nursing home residents have expressed despair at what they 
perceive to be a 'life sentence' in a nursing home. The mental illness and 
anxiety experienced by Aboriginal old people has been described as severe 
homesickness by Aboriginal healers. The Inquiry was told that 'the prospect of 
dying away from one's country and family causes old people a level of distress 
which is seriously unjust'.59 Reintegration with their communities would be 
a more effective treatment for many elderly people with depression than antidepressants
 and other medical therapies. 

[These old people] are miserable and lonely. They have no focus and are cut off from 
their dreaming because they are separated from their community, away from their 
country and not continuing the ceremonial business which is their responsibility.
 The community too is cut off from its dreaming because the old people are not there
 to sing the songs, maintain the sacred sites and direct the business.60 

The maintenance of these rituals is essential to Aboriginal spirituality and the 
cycle of life. 

The living person's spirit comes from the dreaming and is returned to the dreaming and 
country after death. Death and burial on country represents a continuation of 
relationships between people and places.61 

The CAAS and the Central Australian Aboriginal Congress told the Inquiry that 
it is important to ensure, where possible, that Aboriginal old people are able 
to end their lives in their traditional communities. However, community 
workers have found this extremely difficult to organise. Problems include the 
physical difficulties of caring for the frail elderly in isolated and remote areas,
 particularly without adequate support services62; families being unable to cope 
because of poverty; and a reluctance on the part of health workers in 
community clinics to welcome old people back because of the general lack of 
facilities and resources with which they have to work. 

Aboriginal community workers and organisations in Alice Springs have adopted 
a range of strategies to address this situation. Attempts have been made to 
ensure better and more regular communication between local service providers 
and Aboriginal groups and more effective assessment and placement of old 
people in nursing homes. Evidence indicated that while the adoption of these 
strategies has led to more effective advocacy on the part of the Aboriginal 
elderly, they have also posed some threat to the operation of nursing homes in 
Alice Springs: 

Human Rights and Equal Opportunity Commission Page 705 

In Central Australia there is an obvious contradiction between attractive 
notions of consumer rights or social justice policies of government and a funding 
system for nursing homes which continues to encourage the residential care industry 
to fill its beds. In Central Australia these beds are now usually filled by 
Aboriginal people, despite nursing homes being built with non-Aboriginal people 
in mind... The rights and mental wellbeing of a proportion of the aged population 
cannot be guaranteed, simply because they are elderly and Aboriginal. This flies 
in the face of current grandiose government claims about equity and equality in 
aged care.63 

The Inquiry was told there is an urgent need for the development of services 
to enable Aboriginal old people to remain in their communities and 'die with 
dignity where they choose'. The range of services would include respite care 
for carers and culturally appropriate residential care for those who require it.64
 Appropriate responses could also include the development of protocols for 
minimum standards of care for people remaining in remote areas and the 
provision of financial support to a nominated carer who would be responsible 
for ensuring that basic standards are met. 

A recent study undertaken by the Central Australian Aboriginal Congress found 
that most Aboriginal people caring for the frail and elderly were not accessing 
the home and community care services available to them because they were 
largely inappropriate to meet their needs. 'Some had preferred to go without 
these services rather than change their life to fit the needs of service providers. 

Most had not had the opportunity to use them at all'.65 Clearly, further 
consultation and research need to be undertaken to ensure that appropriate 
services are developed in consultation with Aboriginal people and provision is 
made for Aboriginal control of culturally appropriate services. 

Young People 

It is difficult to determine how many Aboriginal young people are affected by 
a mental illness. The Inquiry was told by several child and adolescent 
psychiatrists that they believed psychiatric problems were widespread among 
Aboriginal youth, particularly among adolescent boys and young men — but 
that little epidemiological data is available.66 

One child psychiatrist told the Inquiry's Cairns hearing that the 1986 census 
showed there were over 10,000 Aboriginal young people under the age of 19 
living in the region — yet he had never had a client who was Aboriginal.67 

Presumably there must be a need for an Aboriginal child and adolescent service.
 We don't see anybody at all unless they have some concomitant medical problem 
[for example, deafness] and are referred to the Health Department. So its really 
a bit of a mystery to me why people aren't detecting disturbance among children
 or why they're not referring.68 

Page 706 Mental Illness Inquiry 

However, an Aboriginal worker from the same region told the Inquiry that 
serious problems exist, including problems related to mental health, and there 
is a desperate need for services in regional communities. 

There are no services to counsel parents or juveniles, even though there's an 
extremely high rate of juvenile offending, and I believe that the communities 
are certainly in crisis when it comes to physical and mental health issues and 
law and order issues.69 

Similarly, in Victoria, the Inquiry was told by one of Australia's leading child 
psychiatrists, that the number of Koori [Aboriginal] children who present or 
receive assistance from child psychiatric services in Victoria you could count 
on one hand. They are not getting through to services and there are complex 
easons for this...70 

The coordinator of the Victorian Aboriginal Mental Health Network noted that 
while very few Aboriginal young people are coming into contact with 
psychiatric services, access to them is 'vital to the survival of [Aboriginal] 
communities'.71 She suggested that one of the major reasons for the under-
utilisation of child psychiatric services is the reluctance to deal with child 
welfare agencies which had previously been instrumental in taking children 
away from their families and communities. Experience of government 
intervention in community affairs has undoubtedly led to justifiable reticence 
and suspicion on the part of many Aboriginal people. 

As the evidence cited above indicates, many Aboriginal juveniles come into 
contact with the juvenile justice system. The Inquiry was told that there are 
clear links between behavioural and mental health problems such as low self 
esteem, alienation and substance abuse, and the high incidence of juvenile 
offending in Aboriginal communities. A study undertaken in Campbelltown, 
NSW, found that 76 percent of the young people going before courts were 
charged with drug and alcohol related crimes.72 

Many young Aboriginal people who come into contact with the juvenile justice 
system also have a serious learning disability. 

Large numbers of Aboriginal children from early childhood through to adolescence have 
a significant hearing disability — hearing loss due to chronic otitis media. [Eighty]
 percent of children tested in [inner Western Sydney] had some degree of hearing 
disability. These are the beginnings of major problems with regard to the ultimate 
lifestyle of significant numbers of these young people. Because they can't hear, 
together with the social disadvantage of their families, they're at risk and 
often drop out of school early. They are then subject, of course, to racial and 
social prejudice. So the steps from there into drug taking and low self esteem 
going on to delinquency and then to the juvenile justice system are not difficult to follow.73 

Human Rights and Equal Opportunity Commission Page 707 

The Inquiry was told there is a potent legacy of mental health problems 
resulting from the high rates of incarceration of young Aboriginal men, many 
of whom spend their formative years (between 15 and 19) in prison. 

Research undertaken in Western Australia indicates that a very strong, dysfunctional 
subculture has evolved in Aboriginal communities as a result of the lengthy periods 
of time that young and adult men spend in jail. In some 
communities, young men see contact with the criminal justice system as a rite 
of passage which is to be expected as part of the transition to manhood. Many 
Aboriginal juveniles who are in institutions have fathers who are or have been 
in jail. 

The absence of the adult male becomes particularly critical as the male children reach 
adolescence. As in all cultures, this makes the establishment of boundaries, 
self-discipline and social responsibility difficult to achieve and it also makes 
it difficult for the growing male child to see and learn positive and meaningful 
personal, family, social, educational, and cultural roles. The moral and ethical
 standards become those of a reactive counterculture.74 

One particularly disturbing manifestation of behavioural and mental health 
problems among Aboriginal juveniles is the increasing incidence of suicide and 
other forms of self-directed violence. One psychiatrist who has undertaken 
considerable research with Aboriginal people in the remote Kimberley region 
of WA has identified a substantial increase in youth suicide since the 1970s: 

For instance, in the Kimberleys in the 1960s there was one suicide; in the 1970's 
there were three, and in the 1980s there were 21. This is a substantial increase. 
We also see an increase in violence [against] women, and we see an increase in 
self-mutilation. Now, this is occurring amongst a group of people who are getting
 younger. If we look at the suicides up to 1988, two of 17 were aged 20 or less. 
In 1988 and 1989 there were eight suicides, and six of those were aged 20 or less.75 

Those committing suicide are the children of a generation of people who were 
taken away from their families and suffered extreme social and economic 
discrimination.76 These experiences have a long-term psychological impact that 
can only be addressed through the involvement of Aboriginal people in the 
development of psychiatric and other services. Organisations like the Koori 
Mental Health Network in Victoria must have appropriate government support 
to extend their activities to Aboriginal young people. All over Australia, the 
development of programs to divert juvenile offenders from custody and prevent 
their 'criminalisation' is an urgent priority.77 

Page 708 Mental Illness Inquiry 

Women 

Although little direct evidence was received, it is also recognised that the 
experiences of Aboriginal women in caring for people affected by mental illness 
are particularly important. As is the case in the non-Aboriginal community, 
Aboriginal women frequently provide the primary care and emotional support 
for those in their communities who suffer from behavioural problems and 
mental illness. A number of witnesses emphasised the particular psychological 
stresses experienced by Aboriginal women and the important role they play in 
maintaining the mental and emotional health of Aboriginal communities. 

Servicing Rural and Remote Areas 

Many Aboriginal people in Australia are denied the right to adequate mental 
health services because they live in geographically isolated areas. The Town 
Clerk of one Aboriginal community in the Northern Territory told the Inquiry: 

We feel that our community and other Aboriginal communities are severely disadvantaged
 in mental health care. If we lived in other centres of Australia we would have the use 
of a broad range of services... At present we only have one trained nurse, and one 
Aboriginal mental health worker visiting approximately two times a year.78 

This severe lack of services is widespread in remote areas of WA, the Northern 
Territory and Queensland — all regions with a comparatively large Aboriginal 
population. Several witnesses observed that the rate of suicide, domestic 
violence and self mutilation in remote Aboriginal communities is high because 
of the high levels of psychological stress associated with daily life.79 However, as 
one Aboriginal community representative told the Inquiry in Queensland, there are no 
primary prevention or other mental health services available. 

As far as I am aware, there is no psychiatrist that ever visits Aboriginal communities. 
Certainly there is no psychologist, or social worker employed on any of the Aboriginal communities...80 

Visiting health workers or resident nursing staff generally bear the responsibility 
for caring for the mentally ill in isolated communities. However, these workers are 
usually untrained in psychiatric treatment or diagnosis and are also responsible for
 providing primary health care to a whole community. This lack of resources combined 
with limited training necessitates a committed but somewhat unfocussed approach to mental health care. 

We have mainly concentrated, not on mental illness, but on mental health and wellbeing.
 The area we cover would be 300 miles to the East and 200 miles to the West and the 
islands off the coast. We are the only two workers in mental health in this area. 
There are 

Human Rights and Equal Opportunity Commission Page 709 

16 major communities, some of them over 1000 people, with probably 30 minor 
communities. We mainly concentrate on primary health care because of the size of 
the area and the job that we have, and we deal with biological, psychological and
social issues... We actually look after everybody, we do not knock anybody back 
no matter what the problem.81 

The Inquiry recognises the importance of the primary health care work 
undertaken by nurses and Aboriginal health workers in remote areas. However, 
the very basic services provided are clearly inadequate. Aboriginal communities 
are denied effective diagnosis and treatment because of the lack of trained 
professionals available. 

The strain placed on individual health workers is immense. One Aboriginal 
mental health worker told the Inquiry that health authorities often assume that 
because she is Aboriginal, she is automatically able to relate to and care for 
all Aboriginal people regardless of their medical needs; that government service 
providers feel that by employing one Aboriginal worker, they are adequately 
addressing the needs of Aboriginal people in isolated areas. 

Sometimes you must do the reverse and put in place money and resources for Aboriginal 
communities to explore the mental health needs of their community with government 
workers in association with the President of the community or in association with 
health workers.82 

This is not easily done, however. The Inquiry was told that when psychiatrists 
do visit remote communities (usually because someone has suffered an acute 
episode and is being evacuated to a regional hospital to be treated) they are not 
perceived as having 'credibility'.83 

A psychiatrist has to be accepted in those [traditional and remote] communities. 
I feel very strongly that Aboriginal people on those communities should be treated, 
if possible, on those communities if practicable. It is very important not to 
alienate them from their own people. [When people are taken to regional centres for 
treatment and returned home] it is very difficult for people on communities to 
accept them back on me community... Now, I do accept that there are times when 
people have to [be sent away for treatment] but I would like to see that only as 
a last resort.84 

As indicated earlier, many Aboriginal people living in geographically isolated 
areas are taken away from their communities to receive psychiatric treatment. 
Rather than improving their mental health, this frequently heightens their sense 
of alienation and mental distress. It is crucial for government service providers
 to recognise the rights of Aboriginal people to receive adequate mental health care 
— and that this requires adaptation of services, including in relation to their 
geographic location. There must be a clear recognition of the particular cultural 
needs of Aboriginal people and the efficacy of providing appropriate 

Page 710 Mental Illness Inquiry 

mental health care to those living in remote areas — before their needs become 
acute. 

The Need for Culturally Appropriate Services 

Witnesses presenting evidence to the Inquiry were in general agreement that 
existing services for Aboriginal and Torres Strait Islander people are seriously 
inadequate and culturally inappropriate. Many factors have contributed to this 
situation. They include: a lack of knowledge and understanding of Aboriginal 
and Torres Strait Islander perspectives and cultures; the way people conceptualise 
and define illness and health; a limited understanding of the nature and scope of
 mental health needs within Aboriginal and Torres Strait Islander communities; 
a lack of consultation by Governments and medical professionals with indigenous
 Australians; and a lack of education and training. 

The network of psychiatric services in Australia is designed to meet the needs 
of the mentally ill who present in the European manner. Consequently, there are
 no special psychiatric services...[or] specific policies for the diagnosis and 
treatment of Aboriginal people with mental illness.85 

The particular historical and social context in which mental illness among 
Aboriginal people occurs has already been described. It is clear that mainstream 
service providers must be cognisant of these issues in the development and 
delivery of mental health services to Aboriginal communities. As the New South 
Wales Aboriginal Mental Health Report found: 

Disturbances of psychological and emotional functioning are common in the 
Aboriginal community and mental health services are needed and wanted. 
Mainstream community mental health services are neither functionally 
accessible nor appropriate to the social and cultural needs of the Aboriginal
 community.86 

The inappropriateness of mainstream services for Aboriginal people was 
summarised by one Queensland witness: 

The current psychiatric system has a basic underlying cultural difference which 
creates for Murris [Aborigines] increased difficulties in dealing with mental 
health problems. Any form of incarceration, isolation, removal from family,
 friends, and the Murri community, is fundamentally alien to culturally 
appropriate methods of dealing with any Murri cultural problem. [For example] 
one person I spoke to related to me how her family would pack up and move 
to each town that she was moved to. They followed her from one hospital to 
another to give her the support that she needed... Removing Murri people from 
the Murri community and placing them within an alien psychiatric system is 
like trying to force a square peg into a round hole. We do not fit.87 

Human Rights and Equal Opportunity Commission Page 711 

While Aboriginal people recognise that there will always be a need for the 
provision of acute care in facilities like hospitals, the Inquiry was told that 
major reforms are needed to ensure that they are able to utilise mainstream 
facilities, without feeling alienated and suspicious of them. 

Many Aboriginal and Torres Strait Islander people do not trust non-Aboriginal 
people or their systems, including psychiatric systems. In most cases it would
 be a great deal easier for an Aboriginal worker to develop a trusting 
relationship with an Aboriginal patient... It is our belief that existing services
 are not utilised because a trusting relationship has not been developed. This
 means that therapy is not effective and treatment is based totally on medication.
 Without culturally aware psychiatric support as well as the appropriate 
medication (when needed), the people admitted to hospital are not being provided
 with the same equality of opportunity in terms of service provision. Indeed, 
when trust has not been developed, the mistrust only exacerbates stress and
 hence the illness.8 

The report of the National Aboriginal Health Strategy recommended important 
ways of facilitating more culturally appropriate and accessible mental health 
services: employment of Aboriginal liaison officers to communicate between 
psychiatric ward staff and Aboriginal Health Service staff and the community; 
and employment of specialist psychiatric Aboriginal health workers in 
Aboriginal communities.89 Unfortunately, despite the fact that these recommendations
 were made early in 1989, evidence to this Inquiry confirmed that 
effective implementation has not been achieved. 

While the involvement of Aboriginal people in service provision is crucial, non-
Aboriginal service providers have responsibilities too. Psychiatrists and other 
mental health workers must develop strategies for extending mainstream 
services to Aboriginal people and ensuring that diagnosis and treatment are 
culturally appropriate. 

Because Aborigines constitute less than two percent of the population, it is
 very easy to avoid ever being involved with them at all... Consequently, if 
the psychiatrist is to be of assistance, it will be necessary for each and 
every one of us to adopt a positive sense of awareness of the issues concerned 
and to demonstrate a willingness and availability for this psychiatrically
 neglected section of the...community.90 

The WA Branch of the RANZCP suggested several practical ways psychiatrists 
could more effectively service their Aboriginal patients. 

Psychiatrists should be encouraged to develop an awareness of and a concern
 about the present deficiencies in the prevention, recognition and treatment 
of psychiatric illness in Aboriginal people [through] educational programs. 
We also suggest that the psychiatrists' role should be to facilitate 
psychiatric care amongst health workers in the field with rural practitioners,
 the Royal Flying Doctor Service etc. Psychiatrists should also be encouraged 
to participate in the administration of existing services and to visit rural 
centres regularly.91 

Page 712 Mental Illness Inquiry 

Many witnesses referred to the need to train Aboriginal and Torres Strait 
Islander mental health workers to work both in mainstream programs and 
community controlled services. 

While the need for culturally appropriate services is clear, the evidence 
suggested that Aboriginal communities face major financial and philosophical 
barriers in their attempts to become more involved in service provision. 

Obtaining the resources and placements for training Aboriginal mental health 
workers has been identified as an important area of need, particularly in remote 
areas such as those in WA, the Northern Territory and Queensland. The 
Inquiry was told that although Aboriginal health services often employ 
specialists, they are usually non-Aboriginal people who do not have the cultural 
knowledge necessary to make accurate diagnoses or communicate well with 
patients. In this context, considerable responsibility is often placed on 
Aboriginal health workers. 

Our medical officers find it very difficult at times to [diagnose] and need to 
work very closely with our health workers...but it is very difficult with our
 health workers as well, because none of the information of the western medicine
 or western mental health has come over to our side... We do not have any modules
 at Batchelor College, where health worker training goes on, in mental health. 
Medical professions...have fixed ideas on illnesses and Aboriginal people are 
feeling that a lot of organisations actually guard against [wanting] to give 
information over to us. It is very difficult to acquire this knowledge.92 

One psychiatric nurse who works closely with Aboriginal health workers in 
remote communities emphasised the importance of training — not only because 
of the need for additional expertise within communities but also because of the 
high 'burn out' rate among health workers: 

Aboriginal health workers do a lot of mental health work but they actually do not
 know how to look after themselves, because they get tangled up with a lot of 
emotional issues on the communities... They certainly give advice to other 
Aborigines in communities but they do not know much about mental illness. 
There are people with major illnesses on the communities that are given 
psychotropic drugs... These people have been given treatment without people 
looking after them who have any idea about the drugs they have and the side 
effects. So I feel that it is very important that Aboriginal health workers 
get some kind of grounding. I was talking to a couple of teachers from 
Batchelor College yesterday and I said, 'we should be doing something about
 mental health education for Aborigines' and they said 'we do not feel that 
Aboriginal health workers are able to handle it', so there is certainly a 
lot of educating to be done with the educators.93 

There is no one particular service or philosophy which can be identified as a 
model for service provision for indigenous people. While Aboriginal people 
throughout Australia suffer similar difficulties concerning mental health, the 
heterogeneous nature of Aboriginal communities and the differences between 

Human Rights and Equal Opportunity Commission Page 713 

those in urban, rural and remote areas make it important for individual 
communities to work with mental health professionals to identify areas of need 
and strategies for reform. One instructive case study in this regard is Wilson's 
Patch in Western Australia. 

Wilson's Patch 

The Aboriginal community at Wilson's Patch, about 280km north of 
Kalgoorlie, received considerable media coverage in December 1992 when 
allegations were made that three mentally ill Aboriginal people being cared for 
in the community were being mistreated. 

The allegations concerned three former patients of Graylands psychiatric 
hospital in Perth who had been released into the care of the community.94 It 
was claimed that they had been detained in 'cages' and 'tethered' to trees. The 
Inquiry's attention was drawn to the matter following representations from 
Aboriginal people involved with the community at Wilson's Patch, politicians 
and journalists. 

The Wilson's Patch community was established by Mr Victor Isaacs to provide 
an alcohol-free community where Aboriginal people with substance abuse 
problems could live in a supportive and healthy environment with their own 
people. The community began caring for former psychiatric patients in 1988, 
following the discharge of one of several Aboriginal people from Graylands 
into Mr Isaacs' care. The WA Health Department supported the initiative as a 
positive attempt to deinstitutionalise Aboriginal people with psychiatric 
disabilities.95 

In its report to the Health Minister in December 1992, the Health Department 
observed: 

When the arrangements were established, the community appeared to be well run... 
Routine medical and health supervision has been provided by weekly, and more 
recently, fortnightly visits by community nursing staff. The present community
 nurse is a qualified mental health nurse and is responsible for administering 
medication and providing general health supervision. The previous doctor in 
Leonora was also a regular visitor. However, under the current doctor patients 
are transported to Leonora for medical care.96 

In November 1992, one of the mentally ill community members 'absconded' from the 
community and made a number of allegations to police, claiming that she had 
been starved and locked up in a 'cage'.97 

Following this incident an unprecedented level of attention was focussed on the 
community. Media reports about Wilson's Patch highlighted allegations of 

Page 714 Mental Illness Inquiry 

mistreatment. They included claims that the mentally ill were being subjected 
to physical abuse and neglect; that supervision was inadequate; that pension 
checks received by the community for the mentally ill members were being 
misspent and that several people with mental illness had been held in cages.98 
The ensuing public controversy caused the Minister to order an investigation. 

Information made available to the Inquiry indicated that the fundamental 
difficulty concerning Wilson's Patch was the uncertain relationship between the 
care givers in the community and the Health Department; and the inadequate 
resources made available to the community in caring for their people with 
mental illness. 

Members of the Anglican Social Responsibilities Commission visited the 
community and found that the allegations were unfounded. Rather than neglect, 
they found a small group of people attempting to provide the best care they 
could with extremely limited financial and physical resources: 

The community has only its own resources to care [for people with mental illness]. 
It has received no funding to improve the facilities, nor to provide the 
infrastructure normally associated with the care of people with special needs. 
The buildings have been constructed by the community, without financial or 
material assistance from local, State or Federal government. There is a clear
 need for additional buildings more suited to the community and its work..." 

The Health Department made similar observations in its review of Wilson's 
Patch. While it found that the use of a bough shed (the alleged 'cage') to 
prevent people from wandering during certain times of the day was not 'the 
usual accommodation for people with mental illness in the community', it was 
occasioned by the real need to prevent people from wandering; the need for 
respite time for carers; and the lack of resources to build a more secure 
area.100 The Department concluded: 

The use of these facilities does not appear to have been associated with any 
observable harm. Indeed, the harm they seek to prevent, from wandering patients, 
is very real. However, the secure areas provided fall well below community 
standards and alternatives need to be devised.101 

This case study raises important issues concerning the care and provision of 
support services to Aboriginal people with mental illness. Although the Health 
Department was aware of the initiatives undertaken at Wilson's Patch, the 
Aboriginal carers were basically isolated and completely under-resourced in 
their attempts to provide a secure and comfortable environment for those in 
their care. 

Human Rights and Equal Opportunity Commission Page 715 

Each of the people under care has very serious and difficult behavioural problems 
associated with their brain damage, retardation and dementia which causes 
substantial difficulties for carers even in Graylands Hospital. The challenge of
 providing security in a humane way at Wilson's Patch is very great. Equally, 
while all attention in this inquiry has focussed on the care of patients, much
greater attention needs to be given to the needs of carers. In none of the 
[Health Department] correspondence relating to Wilson's Patch does there seem 
to be the least concern expressed about their needs, although in the general 
society, considerable attention is paid to the importance of providing respite 
and support for the carers of disabled people.102 

The Wilson's Patch case illustrates the immense practical and attitudinal 
difficulties which Aboriginal people face in attempting to provide culturally 
appropriate services for their own people. It is quite irresponsible for 
governments to purport to meet their obligations by supporting community 
initiatives in principle — but failing to provide the financial and other 
resources necessary to provide humane and adequate care. The Health Department's
 own investigation found that: 

Wilson's Patch has provided a generally effective, stable, and caring environment
 in which persons with mental illness can reside... Intemperate allegations about
 the behaviour of carers can only result in an injustice to them, particularly
 when their general quality of care and concern is taken into account.103 

Many Aboriginal people in remote communities throughout Australia manage 
to provide care for the mentally ill under extremely deprived circumstances.
 One of the major results of this incident was a review of the supervision 
provisions for all persons currently subject to the aftercare provisions of the
 West Australian Mental Health Act (see Chapter 4 — The Legal Framework) and the 
development of a State policy on Aftercare which includes guidelines on the 
coordination and monitoring of patients and the responsibilities of mental health 
professionals, including psychiatrists and case-managers. 

Respite Care and Relief 

In Chapter 15 of this report specific attention is focussed on the critical role 
played by family members as carers for those affected by mental illness. It is 
clear from the previous sections of this chapter, and in particular the case-study
 just cited, that adequate recognition of the need for appropriate respite and 
relief for carers is just as important for Aboriginal people.104 

The Importance of Self-Determination 

We support the practice of cross-cultural psychiatry in the short term, but 
long-term strategies must be developed to enable our people to develop the skills 
and resources needed to develop and run our own mental health services.105 

Page 716 Mental Illness Inquiry 

Aboriginal and Torres Strait Islander people told the Inquiry that solutions to 
the mental health problems of indigenous peoples are contingent upon the 
recognition of their human right to self-determination. All Aboriginal and 
Torres Strait Islander witnesses identified the provision of self-determined, 
culturally appropriate services as a key strategy in improving their communities' mental health. 

The most fundamental principle is that of self-determination. This means that
 problems affecting Aboriginal people can only be effectively dealt with if 
Aboriginal people are in control of the process.106 

Self determination, in this context, involves providing Aboriginal people with 
the training, power and resources to determine their own mental health 
strategies within their own terms of reference. In addition to the provision of 
services run by and for indigenous people, it is essential that mainstream 
services are delivered in a culturally appropriate manner and are geographically 
accessible. As many witnesses pointed out, it is useless providing 'appropriate' 
services if the professionals responsible for delivering them are several 
thousand kilometres away from the communities which need them. 

The Royal Commission into Aboriginal Deaths in Custody concluded that: 

Mental health service provision for Aboriginal people constitutes, for the most 
part, mainstream services. As a result, Aboriginal people are particularly 
disadvantaged. Not only are they disadvantaged by their socioeconomic status 
and cultural background, but proportionately more Aboriginal people than
 non-Aboriginal people are disadvantaged by their geographic location, in the
 sense that many live in the rural or remote regions of Australia where
 mental health services are lacking.107 

Aborigines and Torres Strait Islanders are among the most powerless and 
socially and economically disadvantaged groups in Australian society. Despite 
their continuing disadvantage, many Aboriginal communities have developed 
innovative and effective strategies for addressing their problems. As the Central
 Australian Aboriginal Congress told the Inquiry: 

Our strength is that we have survived. We are strong, or we would not have survived.
 Our culture is alive, and is central to our strength. The colonisation process of
 dispossession made us strong. We depend on each other, we understand and support each other.108 

The challenge for Australian governments, the non-Aboriginal community and 
mental health professionals is to build on this strength by providing the training 
and resources necessary to ensure culturally appropriate mental health care. 

In terms of human rights the solutions are not to be found simply...in improved access
 to mainstream services; provision of culturally appropriate services; and culturally self-

Human Rights and Equal Opportunity Commission Page 717 



determined services. Although progress in each of these directions is of extreme 
importance, the bald fact is that the symptoms will not go away even with the best 
service provision until there is real progress on the fundamental cause, which is to
 ensure access to Aboriginal mental health through Aboriginal self-determination in
 all aspects of life — to make possible a dignified Aboriginal life which is viable 
and meaningful as seen and experienced and constructed by Aboriginal people themselves.109 

Page 718 Mental Illness Inquiry 



1. Pat Swan, 200 Years of Unfinished Business, Aboriginal Medical Service, 
Redfern. Paper provided to the Inquiry, p7. 
2. Aboriginal Medical Service Co-operative Ltd, NSW Aboriginal Mental Health 
Report, May 1991, p9. 
3. Ken Wyatt and Richard Wilkes, Fantasy or Reality: Aboriginal Mental Health. 
Paper presented as a submission to the Inquiry, pp9-12. 
4. Central Australian Aboriginal Congress and Anyinginyi Congress Aboriginal Corporation.
 Joint submission, pi. 
5. Barbara Miller, A Socio-Historical Perspective on Aboriginal Intra-Cultural Aggression,
 Aboriginal Coordinating Council, Queensland. Paper provided to the Inquiry, p24. 
6. 200 Years of Unfinished Business, op cit, p2. 
7. Pat Dudgeon, Head, Centre for Aboriginal Studies, Curtin University. Oral evidence,
 Perth 12.2.92, p306. 
8. Wyatt and Wilkes, op cit, plO. 
9. Sarah Dunlop, All that Rama Rama Mob: Aboriginal Disturbed Behaviour in Central Australia,
 Central Australian Aboriginal Congress 1988, p9. 
10. ibid, p7. 
11. Wyatt and Wilkes, op cit, plO. 
12. National Aboriginal Health Strategy Working Party, A National Aboriginal Health Strategy,
 AGPS, Canberra, 1989, pix. 
13. Shane Houston, Coordinator, Tharawal Aboriginal Corporation. Oral evidence, Sydney 
21.6.91, p603. 
14. Prof J Reser, Department of Psychology, James Cook University. Oral evidence, 
Townsville 13.8.91, pl274. 
15. National Aboriginal Health Strategy Working Party, op cit, p286. 
16. Dr Ernest Hunter, psychiatrist, Aboriginal Medical Service, and Fellow, National Drug and
 Alcohol Research Centre. Oral evidence, Sydney 21.6.91, p535. 
17. Reser, op cit, pl279. 
18. Houston, op cit, p604. 
19. Aboriginal Medical Service Co-operative Ltd, op cit, pll . 
20. Dr Jane McKendrick, Koori Mental Health Network. Oral evidence, Melbourne 9.4.91, p249. 
21. Carol Kendall, Coordinator, LINK-UP, New South Wales. Submission, p2. 
22. Hunter, op cit, p546. 
23. Barbara Miller, research officer, Aboriginal Coordinating Council. Oral evidence, 
Cairns 9.8.91, pl0l0. 
24. Houston, op cit, p604. 
25. 200 Years of Unfinished Business, op cit, pp3-4. 
26. ibid, p2. 
27. Hunter, op cit, p535. 
28. Commissioner Elliott Johnston QC, Royal Commission into Aboriginal Deaths in Custody: National R
eport Overview, AGPS, Canberra, 1991, pl5. 

Human Rights and Equal Opportunity Commission Page 719 

29. Pat Swan, psychiatric nurse, Redfern Aboriginal Medical Service. Oral evidence, Sydney 21.6.91, p534. 
30. Harry Pickett, psychologist and counsellor, Centre for Aboriginal Studies, Curtin University.
 Oral evidence, Perth 12.2.92, pp311-312. 
31. Dr John Spencer et al, Social and Cultural Issues Committee, RANZCP (WA), Branch Statement on
 Psychiatric Services for Aboriginal People, pi. Included with submission presented to the Inquiry by Dr David Lord. 
32. Ken Wyatt, Senior Policy Officer, Aboriginal Health Policy Unit, Health Department of Western
 Australia. Oral evidence, Perth 12.2.92, p287. 
33. Reser, op cit, pl275. 
34. Liz Hayden, Aboriginal community representative. Oral evidence, Albany 14.2.92, p453. 
35. See, for example, the submission by Ken Wyatt, Aboriginal Health Policy Unit, Health Department
 of WA, who discussed the influence of spiritual forces on psychological wellbeing. 
36. ibid, p20. 
37. Dunlop, op cit, pl2. 
38. id. 
39. Swan, op cit (oral evidence), p534. 
40. Central Australian Aboriginal Congress, op cit, p9. 
41. ibid, plO. 
42. These issues came to the fore in Queensland recently, where it was alleged that the civil 
liberties of an adolescent Aboriginal boy had been infringed. A report prepared by the Barambah
 Aboriginal Child Care Agency into youth problems at Cherbourg alleged that a young boy was taken 
into custody by police without the knowledge of his parents and taken to the government medical 
officer. He was then allegedly taken to Brisbane, where attempts were made to have him admitted 
to a psychiatric hospital. 1993. 
43. John Hopkins, Coordinator, Disability Services, Central Australia. Oral evidence, 
Alice Springs 23.7.92, pl65. 
44. These concerns were raised in a letter to the Inquiry from Dr Pamela Watson and Maggie Brady, 
research fellow, Australian Institute of Aboriginal and Torres Strait Islander Studies. In it
 they provided a critique of three academic papers on Aboriginal substance abuse in which, they 
suggested: 'uncorroborated claims are used as important elements in the construction of argument,
 relevant information is omitted or misrepresented, there are factual mistakes, and perceived negative
 attitudes or behaviours which are common to most, if not all, human groups are presented as being
 specific to Aboriginal society. As a result of these errors, the articles present accounts of 
drug/alcohol use which are extremely derogatory to Aboriginal people.' 
45. Spencer et al, op cit, pi. 
46. John Lawrence, solicitor, North Australian Aboriginal Legal Aid Service Inc. Submission, p3. 
47. ibid, pp3-4. 
48. id. 
49. Wyatt, op cit, p5. 
50. Watson, op cit, pl511. 
51. Reser, op cit, pi277. 

Page 720 Mental Illness Inquiry

52. Dudgeon, op cit, pp305-308. 
53. Pickett, op cit, p307. 
54. Margaret Collins, administrator, Central Australian Advocacy Service. Oral evidence, 
Alice Springs 23.7.92, pl75. 
55. Jo Harrison, project officer, Central Australian Advocacy Service (CAAS). Oral evidence,
 Alice Springs 23.7.92, pl75. 
56. ibid, ppl75-176. 
57. Central Australian Advocacy Service. Submission, pp5-6. 
58. Central Australian Aboriginal Congress, op cit, p7. 
59. Central Australian Advocacy Service, op cit, p6. 
60. Extract from explanation of a painting by Mantatjara Wilson, included with Central Australian
 Advocacy Service submission, op cit. 
61. Anthropologist Jane Lloyd, quoted in Central Australian Advocacy Service submission op cit, p4. 
62. Central Australian Advocacy Service, op cit, p7. 
63. ibid, p9. 
64. Central Australian Aboriginal Congress, op cit, p8. 
65. id. 
66. Dr Michael Dudley, psychiatrist, Avoca Clinic, Prince of Wales Hospital, Sydney. Oral 
evidence, Sydney 18.6.91, ppl97-198. 
67. Dr John Rigano, child psychiatrist. Oral evidence, Cairns 9.8.91, pl026. 
68. ibid, pl027. 
69. Miller, oral evidence, op cit, plOll. 
70. Professor Bruce Tonge, Head, Monash University Centre for Developmental Psychiatry. Oral 
evidence, Melbourne 9.4.91, p244. 
71. Marjorie Thorpe, coordinator, Victorian Aboriginal Mental Health Network. Oral evidence, 
Melbourne 9.4.91, p246. 
72. Houston, op cit, p604. 
73. Dr Maree Bashir, Director, Community Health Services for Central Sydney. Oral evidence, 
Sydney 20.6.91, p499. 
74. Dudgeon, op cit, p313. 
75. Hunter, op cit, pp536-537. 
76. id. 
77. E Hunter, Problems of Aboriginal Youth in Remote Australia. Information provided to the
 Inquiry. One innovative program to divert young Aboriginal offenders and those 'at risk' 
from remand and detention facilities has recently been instituted in WA. It is jointly funded
 by the Australian Youth Foundation.(Details of the program can be obtained from the Executive
 Director of the Foundation at Suite 302/134 William St, East Sydney, NSW. 
2011.) 
78. Kevin Doolan, Town Clerk, and Mathew Woneaemirri, President, Milikapiti Community 
Government Council, Melville Island. Submission, pi. 
79. Miller, op cit, ppl010-1014. 
80. ibid, pl0l0. 

Human Rights and Equal Opportunity Commission Page 721 

81. Glen Norris, psychiatric nurse. Oral evidence, Darwin 21.7.92, p82. 
82. Chickie Darling, Aboriginal mental health worker. Oral evidence, Darwin 21.7.92, p86. 
83. Norris, op cit, pp82-83. 
84. ibid, p83. 
85. Spencer et al, op cit, pi. 
86. Aboriginal Medical Service Co-operative Ltd, op cit, pi 1. 
87. Alex Goulash, voluntary worker, Aboriginal and Islander Community Welfare Service. 
Oral evidence, Brisbane 15.8.91, pi504. 
88. Wilkie, Thorpe, et al. Submission of the Aboriginal and Islander Community Health Service, Brisbane, p2. 
89. National Aboriginal Health Strategy Working Party, op cit, pl73. 
90. Spencer et al, op cit, p3. 
91. ibid, pi. 
92. Sally Ross, Director, Danila Dilba Aboriginal Medical Service. Oral evidence,
Darwin 21.7.92, p71. 
93. Norris, op cit, p83. 
94. 'Black Mental Patients Held in Desert Cages', Melbourne Age, 10 December 1992. 
95. Stephen Hall et al, Report of Visit to Wilson's Patch, Anglican Social Responsibilities
 Commission, 22 December 1992, p6. 
96. Health Department of Western Australia, Investigation Concerning Aboriginal People 
Discharged from Graylands Hospital to Wilson's Patch: Report to the Minister for Health, 
Perth, December 1992, p2. 
97. ibid, p3. 
98. ibid, p4. 
99. Stephen Hall et al, op cit, p5. 
100. Western Australian Health Department, op cit, pl6. 
101. ibid, pl7. 
102. id. 
103. ibid, pp21-22. 
104. Health Department of Western Australia Mental Health Policy Unit, Draft Policy on 
Aftercare, February, 1993, plO. 
105. Central Australian Aboriginal Congress submission, op cit, p3. 
106. ibid, p6. 
107. Commissioner Elliott Johnston QC, Royal Commission into Aboriginal Deaths in Custody: 
National Report v4, p224. 
108. Central Australian Aboriginal Congress, op cit, p3. 
109. Dudgeon, op cit, p315. 

Page 722 Mental Illness Inquiry 

Chapter 24 

PEOPLE FROM NON-ENGLISH SPEAKING BACKGROUNDS 

There is a pattern of systematic disadvantage for the migrant group. The health care 
system has its own culture... Most workers take this culture for granted. We don't 
appreciate that health care is practised in very different ways in different countries 
and it depends largely on culture.1 

Approximately 3.2 million Australians, or 20 percent of the population, are 
migrants from non-English speaking countries or the children of migrants from 
such countries. That is, they are from a non-English speaking background.2 
Evidence to the Inquiry from consumers, consumer advocates and service 
providers clearly established that although Australian society is becoming 
increasingly culturally diverse, the current mental health 'system' is failing to 
meet the needs of a large number of people with mental illness from non-
English speaking backgrounds. 

The Inquiry heard that while the Commonwealth Government and most State 
and Territory Governments emphasise access, equity and social justice in their 
health policy statements, these objectives are yet to be realised in the form of 
culturally appropriate services and community education. The provision of 
effective early intervention and treatment services for people from non-English 
speaking backgrounds is also essential if the implementation of the National 
Mental Health Policy is to address the needs of one in every five Australians. 

The Migration Experience 

Since most people from non-English speaking backgrounds have come to 
Australia as migrants, the migration process itself has become a significant 
focus in considering the prevalence, diagnosis and treatment of mental illness 
among different ethnic groups. 

The question most consistently asked in the research literature on migration and
 mental illness has been: Is migration associated with an increased prevalence of
 mental illness?3 

Studies on the connection between migration and mental illness have concentrated 
on two issues. First, the migration experience as a causal factor in the development
 of mental illness, and second, the prevalence of mental illness 
among people who choose to migrate. The research on the causes of mental 

Human Rights and Equal Opportunity Commission Page 723 

illness is generally inconclusive — because 'Very few adequately controlled 
community-based studies of the prevalence of psychiatric disorder in immigrant 
communities have been carried out, and results have been quite variable'.4 

Recent studies in Australia and overseas suggest that the emotional and physical 
trauma and disruption sometimes associated with migration to and settlement 
in a new country may create psychological distress or exacerbate existing 
vulnerability to mental illness.5 

However, it is difficult to isolate definitive causal factors in the development 
of mental illness among migrant groups. Dr Elsa Bernardi, a bilingual 
psychiatrist who works with patients from non-English speaking backgrounds, 
presented evidence that the diverse cultural origins and individual experiences 
of many migrants pre and post migration make generalisation very difficult.6 
Other witnesses agreed that a wide variety of factors may affect a migrant's 
mental health and predisposition to mental illness: 

Research tells us that the stress associated with the migration process is a factor
 in relation to the risk of the development of mental illness. We know that issues
 such as the reception and ease of settlement in the host country, the size of the
 ethnic community and its capacity to provide support, accessibility and 
availability of services, discrimination and racism, underemployment and employment
 of migrants are all crucial issues with respect 
to the impact of migration on the mental health of individuals.7 

This view is supported by a recent review of Australian research on ethnicity, 
migration and mental illness which found that there is no conclusive evidence 
on the incidence of mental illness among migrants. The researchers concluded 
that 'it is not the culture of one's ethnicity per se, but the interaction between 
culture and societal forces and the immigrants' status and experience in society 
that accounts for a given profile of immigrant mental health'.8' 

Groups Particularly at Risk 

The Inquiry heard evidence that several groups within the non-English speaking 
background community are more susceptible to mental illness. Refugees are 
particularly vulnerable. Others at risk include the elderly and women. 

Refugees 

Refugees, particularly those who have experienced torture and trauma, face a 
high risk of developing a mental disorder. Australia receives between 10,000 
and 15,000 refugees and displaced persons each year under its refugee and 
special humanitarian immigration programs. The Inquiry was told that a significant 
number of these migrants are 'experiencing physical and mental 

Page 724 Mental Illness Inquiry 



health problems as a result of their torture experience'.9 No figures are 
available to establish how many refugees have been victims of such treatment. 
However, some witnesses suggested that at least 10 percent and possibly as 
many as 15 percent of refugees are suffering mental illness as a result of 
maltreatment prior to their migration.10 

Professor Derek Silove, a psychiatrist who has worked with many refugees, 
gave evidence that those who have come to Australia under the humanitarian 
program are particularly at risk because of the human rights violations they 
have suffered. 

They are dispossessed, dislocated, they suffer psychological disintegration and they 
arrive in a country where they become disempowered. Ten to twenty percent of these
 people have been subject to formal torture and that's probably an underestimate, 
but almost all of them have been subjected to what we call 'organised violence' which 
is a World Health Organisation term to cover a wide range of trauma to do with civil
 unrest, dispossession, persecution by authorities, famine, war and other forms of
 violence carried out in societies that are disintegrating." 
Professor Silove told the Inquiry that torture survivors could, on the basis of 
their psychiatric needs, be divided into two groups: those suffering from the 
more traditionally recognised psychiatric disorders such as schizophrenia and 
manic depressive disorder, and those suffering from other psychiatric disorders 
which were the direct consequences of torture and 'refugee trauma'. The most 
common psychiatric condition associated with this second group is 'post 
traumatic stress disorder', a term used to describe a range of psychological and 
psychiatric phenomena which manifest themselves in individuals who have 
suffered extraordinary physical and emotional trauma. Post traumatic stress 
disorder (PTSD) results from 'a terrifying calamity involving threatened or 
actual loss of life or severe bodily harm. The syndrome lasts for at least six 
months and can be distinguished from the usual period of distress that would 
be expected to follow the catastrophe.'12 

The Clinical Coordinator of the Rehabilitation Unit for Survivors of Torture 
and Trauma in Brisbane described the symptoms associated with PTSD: 

The effects of torture can be conceptualised as physical, psychological, social 
and spiritual. The physical effects are the easiest to treat. The other three effects
 are much more difficult because the aim of torture is to destroy without actually 
killing. A torture survivor is typically quite disabled socially and suffers serious
 disruption to mental health. Physiologically there is upset in terms of sleep, 
appetite and energy level. Cognition is usually disturbed with memory problems, 
concentration and orientation problems, and stress symptoms [such as] hallucinations,
 panic attacks, and flashbacks [are common]. Values and beliefs may be shattered and 
identity and integrity destroyed... These symptoms can make the initial settlement 
tasks almost impossible for the torture survivor and their family.13 

Human Rights and Equal Opportunity Commission Page 725 

Mental illness among refugees can sometimes be difficult to diagnose. The 
NSW Service for the Treatment and Rehabilitation of Torture and Trauma 
Survivors (STARTTS) said that in addition to the kinds of symptoms described 
above, mental health problems associated with torture and trauma can also 
manifest themselves somatically in conditions such as '.. .chronic pain, arthritic
 conditions, broken bones, brain damage, and cardio-pulmonary disorders'.14 

It is not uncommon for torture survivors to visit general practitioners for 
treatment of these physical symptoms. However, general practitioners often fail 
to make a diagnosis of PTSD because they are not trained to recognise it. As 
a result, there are refugees in our community in need of professional assistance 
whose problems remain undiagnosed or incorrectly diagnosed. In either case 
they are not receiving appropriate treatment. 

Evidence presented to the Inquiry indicated that the identification of PTSD 
among refugees and the provision of specific psychiatric services are comparatively
 recent developments in Australia. The Inquiry was told that although - specialist 
services are available in Melbourne, Sydney and Brisbane for treating torture and
 trauma survivors, they are unable to meet demand because of their limited financial
 and professional resources.15 Professor Silove spoke of the urgent need for a coherent
 and sustained approach to the psychological problems faced by refugees: Policy in 
this country in dealing with the psychiatric and psychosocial problems of refugees...
is somewhat piecemeal [and] ad hoc. [For example] there is no coherent screening 
program for psychiatric and psychological problems. There are screening programs 
for physical disorders when refugees come, which are partially effective — but 
none to screen for family problems, psychosocial problems, and no coherent, nationwide
 policy and set of procedures for dealing with this vast problem across the country.16 

At the time of writing it appears clear, tragically, that this need will not 
diminish — assuming our policies on humanitarian and refugee intake and 
family reunion continue. The atrocities perpetrated in the former Yugoslavia 
will, for example, mean a significantly increased number of PTSD victims requiring 
assistance. Indeed, the level of savagery recently inflicted on tens of thousands
 of civilians appears to be posing new challenges to those who seek 
to care for its victims.17 

The Elderly 

The Australian population is ageing rapidly. Projections suggest that by the 
year 2001, more than 20 percent of individuals aged 60 and over will be from 
non-English speaking backgrounds.18 The Inquiry received expert evidence 

Page 726 Mental Illness Inquiry 

concerning the effect the changing demographics of our ageing population is 
having and will continue to have on service provision: 

Migration to Australia has followed a wave pattern, with the sequence from World
 War II being firstly East European refugees... Secondly, migrants from Western 
Europe, then migrants from the Mediterranean: the Italians, the Greeks, the 
Yugoslavs, then [more recently] the Asian migrants and the refugees from Indo-China
... The wave pattern of immigration has resulted in...an increase in the proportion 
of older [migrants]... We're now seeing more elderly with depression and dementia 
and the shortfall of services to provide for those problems in the elderly migrant
 who doesn't speak English.19 

As the evidence analysed in Chapter 17 indicates, personal networks and 
support systems are extremely important in maintaining mental health as people 
age and become more dependent on those around them for physical and 
emotional care. For many elderly people from non-English speaking backgrounds 
the situation becomes particularly complicated. Many older migrants 
who came to Australia from non-anglophone countries may have learnt English 
comparatively late in life. As a result of dementia and other illnesses, they lose
 their linguistic abilities in English and, sometimes, their native tongue. One 
expert specialising in transcultural psychiatry told the Inquiry: 

It is well known that with age [people] have reduced resources, both cognitive, 
emotional and physical, to look after themselves. The question is much more 
complicated for the person from non-English speaking background. His even meagre 
knowledge of the English language is further reduced, completely disappears, 
and when he is put in institutions where he all of a sudden after many years 
of particular life experience finds himself in a completely new situation ranging
 from not having people with whom he could communicate to having food which has 
never been part of his diet — I think this could be seen, in a way, as significant 
discrimination against these people.20 

For elderly people from non-English speaking backgrounds, the loss of 
language can lead to social isolation and very real difficulties in accessing aged 
care and psychiatric services. Several witnesses told the Inquiry that a 
significant proportion of elderly people from non-English speaking backgrounds 
are affected by mental illness. However, they have not been diagnosed or 
received professional support for their illness because they are so isolated: 

The recognition of mental illness happens much later with non-English speaking 
background people than among the Australian population... The result of this is 
that we are meeting these people in the total crisis situation... I am often sent 
or referred to people who might be lonely — and several sentences exchanged with
these people make me realise they are extremely disturbed; disturbed to the point
 that if somebody will virtually speak a sentence to them, they will realise that.21 

This lack of early diagnosis and intervention can precipitate chronicity and 
institutionalisation. One witness described a number of situations in which she 

Human Rights and Equal Opportunity Commission Page 727 

had encountered elderly people from non-English speaking backgrounds who 
were highly disturbed.22 The Inquiry was told of several cases where elderly 
people had contact with police and psychiatric services as a result of their 
mental illness, but were still living in the community unassisted. One example 
involved an Eastern European man in his seventies with a severe psychosis: 

He believes that he is Jesus; he talks about [his] war experience and has an 
extremely violent imagination. He wants to kill everybody around him... [On] 
referring his case to Mental Health, I find out that there was an example, five y
ears ago, when he threatened the neighbours with a firearm...then the police were
 called. The gentleman was taken to Royal Derwent Hospital... He was discharged
 to the community... The tension which is building there is just incredible. I 
contact Mental Health and they say, 'well, we'll visit'. They visit; they never 
contact me back. The gentleman is still in the community.23 

Elderly women from non-English speaking backgrounds are particularly at risk 
of having an undiagnosed mental illness because they are one of the most 
isolated groups in the community. 

The ageing women of non-English speaking backgrounds are particularly disadvantaged
... Many never learnt English. Most of them had poor schooling in their country of
 origin. They were employed (if they were employed at all in Australia), in poorly
 paid, unskilled jobs which put them at increased risk of danger to their health. 
Unfortunately this group, the group that needs a lot of assistance, is forgotten by
 the services and tends to under-utilise the services and thus doesn't show up in
 the statistics.24 

Another witness described the case of an elderly woman living in public 
housing who had been behaving erratically over a long period of time and 
eventually became psychotic. She did not receive any assistance until an 
incident of self mutilation which resulted in the police being called: 

The lady is placed in [hospital] in [a] total crisis situation. She is properly
 assessed as suffering from deep psychosis, and now the search begins for a place
 for her... [The nursing home will not take her [because] although she is over 65 
she can cook and clean and look after herself. She is not demented, so she is not
 a candidate [for an institution]... She is placed [back] in the Housing Commission...
 The community worker and myself are already receiving very worrying sounds from 
community nurses and all possible Departments who are in contact with her... 
We all know that she needs help, it is just we cannot do anything about it.25 

Women 

In addition to elderly women and those who are refugees, women from non-
English speaking backgrounds may generally be at increased risk of developing 
a mental illness. The Inquiry was told that in addition to the emotional and 
psychological pressures affecting women who are mothers and carers, those 

Page 728 Mental Illness Inquiry 

from non-English speaking backgrounds face difficulties related to their 
ethnicity and their disadvantaged position in Australian society. 

A women's agency from our most populous State, NSW, presented the Inquiry 
with the results of a mental health survey of women from non-English speaking 
backgrounds conducted in June 1990.26 The main concerns identified were 
depression and the subsequent over-use of tranquillisers, social isolation 
resulting from migration and social dislocation, the stigma associated with 
mental illness, culture conflict and feelings of powerlessness, and the lack of 
culturally appropriate treatment services. All of these factors were also 
identified in evidence in other States. 

Many women from non-English speaking backgrounds experience loneliness 
and isolation as a consequence of migration: 

[Adjusting to life in a new culture] is a painful process; women often lose the
 support of the traditional women's cultural group. Simultaneously, they are 
often subjected to rejection and criticism if they move towards accepting the 
new culture's norms. This conflict increases psychological pressure on women
 from other cultures.27 

Not only do women from non-English speaking backgrounds face the personal 
difficulties of adjusting to a new society, but they must often be a major source
 of emotional support for their families and extended families. They often 
provide additional economic support to the family, frequently working in 
unskilled, poorly paid jobs. Evidence to the Inquiry suggested that these 
psychological pressures are exacerbated by cultural differences and linguistic 
problems which further isolate women from support networks. 

The Inquiry was told that these pressures make women from non-English 
speaking backgrounds one of the groups most at risk of developing a mental 
illness.28 A recent study found that the largest client group presenting at the 
Multicultural Psychiatric Centre in Perth were immigrant and refugee women. 
These women suffered from 'a lack of interaction with partners because of their 
long working hours, lack of contact outside the home, coping with a job as well 
as family commitments, the pressure of tedious jobs, and the possibility of 
retrenchment, or being housebound with young children' .29 

These findings were also reflected in submissions to the Inquiry from advocacy 
and support groups. One witness noted that social isolation and the pressures 
of caring for a family often culminate in the development of depression and 
other serious illnesses: 

Exposure to constant mental and physical stress, with no outlets for verbalising 
the various problems these women face as mothers, carers, nurturers, employees, 
in unstimulating, 

Human Rights and Equal Opportunity Commission Page 729 

unskilled, impoverished environments, forces them to internalise these problems 
[which] unconsciously manifest themselves into somatic pains and complaints 
which have no physical aetiology. They seek medical advice [from predominantly
 male, English speaking doctors] who usually prescribe pain relief drugs or, 
if the woman is depressed or hyperactive, anti-depressants and tranquillisers.30 

While alleviating the immediate symptoms of distress, drug treatment in these 
circumstances does little to address the fundamental cause of the problem. If 
the patient is not an English speaker misdiagnosis can occur — as exemplified 
in the case of a Southern European woman brought to Australia as a proxy bride: 

[Her husband] kept her in isolation. She became subject to panic attacks, and 
could not leave the house. Her husband left work to 'care for her'. However the 
attacks became so severe that she was periodically institutionalised. The mental
 health service relied on the husband to interpret, and decided [that she was] 
depressed and mildly schizophrenic. This revolving door syndrome continued until
 a Grant-in-Aid Worker and proper interpreter became involved. It was then 
established that the woman had panic attacks because she did not have a word 
of English, did not know how to use public transport, and could not be autonomous.
 All she needed was English classes and information to resolve her situation.31 

Accessing Services 

They seek quality, relevant and accessible services, and often encounter similar 
difficulties when trying to obtain services. However...by virtue of their differing 
language, culture, and subcultural backgrounds [they] often require a differing 
approach to the provision of psychiatric services if they are to obtain accessible, 
relevant, quality services, which also uphold their fundamental human rights.32 

Members of cultural minority groups are often disadvantaged in terms of access 
to appropriate mental health services and preventive care.33 Evidence submitted 
to the Inquiry by community workers, service providers and consumer 
advocates indicated that mainstream services are under-utilised by people from 
non-English speaking backgrounds. Witnesses suggested that this is not because 
mental illness is any less prevalent in these communities, but relates to three 
factors: reluctance by members of ethnic communities to use the services 
available; barriers to accessing services once a decision has been made to seek 
help; and the overall lack of culturally appropriate services staffed by 
appropriately trained mental health professionals to treat people from non-
English speaking backgrounds. 

Reluctance to Use Services 

As discussed in Chapter 3, other cultures perceive the behaviours and 
phenomena which Western societies define as 'mental illness' in a variety of 

Page 730 Mental Illness Inquiry 

ways. Evidence presented to the Inquiry suggested these differing perceptions 
of mental illness can have a significant impact on how the onset of an illness 
is conceptualised and, subsequently, whether assistance is sought from a 
psychiatrist or general practitioner. 

The personal cultural history and tradition of the individual as they are 
reflected in the mental health and illness are actually an integral part of
 the presentation of both the individual and of the illness, and not only some 
phenomenon, something on top of universal, biological reality.34 

People from non-English speaking backgrounds are often reluctant to seek 
medical intervention because of their 'cultural history'. Mental illness is 
stigmatised in many cultures — either because of the perceived influence of 
malevolent forces or because it involves behaviour that deviates from what is 
considered to be normal. 

There is a degree of ignorance and stigma within certain migrant groups which
 lead them to care for their mentally ill at home for the longest time possible.
 [Because] there's a lack of extended family in Australia...this puts an 
incredible burden on the family to try to manage and they often only come to 
attention when there's a major crisis... They may come to treatment too late.35 

In some cultures the unusual behaviour associated with mental illness is not 
perceived as being a manifestation of a psychological problem but a spiritual 
one. Medical intervention may not be sought because it is not seen as offering 
a solution to the problem. In these circumstances people from particular cultural 
backgrounds who believe that mentally ill people have been 'cursed' may prefer
 to obtain assistance from practitioners of folk medicine and 'magicians' .36 

A social worker presented evidence to the Inquiry based on her study of two 
Italian and two Vietnamese families in Perth with relatives suffering from 
schizophrenic illness.37 In each of these families the development of mental 
illness was attributed to an external physical event. For example, one family 
attributed their child's schizophrenia to a beating inflicted some years earlier 
by a school teacher.38 The witness noted that: 

It is interesting that all four families 'somatised'39 the onset of mental 
illness to explain what was otherwise unexplainable... Three of the families 
seemed to feel no stigma because they had been able to link the ensuing illness
 to a causal factor. This is a feature of families from traditional backgrounds.40 

The Inquiry was also told that people from non-English speaking backgrounds 
may be reluctant to seek early intervention because of a fear of government 
services. In particular, refugees and survivors of torture may regard 

Human Rights and Equal Opportunity Commission Page 731 

government with suspicion because agencies of the state have been instrumental 
in perpetrating human rights abuses against them in their country of origin. 

To many people coming from a country with an oppressive regime, any service 
provided by the government is often not trusted. Our Western model of a benevolent
 and safe government is one we are very fortunate to have, and one which is
 not shared by a majority of the world's countries. We must ensure that 
services are introduced to each culture appropriately and encourage people 
to use them — not just expect them to, simply because they are there.41 

Barriers to Obtaining Referrals and Services 

People from non-English speaking backgrounds face particular barriers in 
obtaining referrals and accessing mainstream treatment services. The under-
utilisation of services frequently reflects the attitudes of both the ethnic 
communities and the service providers themselves: 

To put it bluntly, mental health theory and services are geared in every way
 to our English speaking Anglo-Saxon majority and members of ethnic minority 
groups simply must fit in or miss out.42 

In Victoria the Inquiry heard that government health agencies have failed to 
make the mental health services accessible to migrant communities — and that 
this failure is compounded by the lack of data on utilisation rates by people 
from non-English speaking backgrounds. The lack of effective needs analyses 
and focussed service delivery can further disadvantage the very groups already 
deprived of adequate access to care.43 

In NSW the Inquiry was told people from non-English speaking backgrounds 
have less access than the rest of the population to information about mental 
illness and advocacy services. They are doubly disadvantaged because of the 
stigma attached to mental illness and by having to deal with services which are 
not designed for their use. It has been suggested that this is due, at least in 
part, to the lack of consideration given by mainstream services to identifying 
and targeting the needs of the ethnic communities in local health areas: 

Services are either unaware of the needs of their local ethnic population or 
they put into place systems that only pay lip-service to the problems of access and equity.44 

While the translation of material into community languages is often seen by 
health authorities as ensuring better access to services, evidence received 
by the Inquiry indicates that this is frequently not the case: 

NESB communities do not have equitable access to information essential for the 
maintenance of health and early and effective treatment of illness. There is a paucity of

Page 732 Mental Illness Inquir 

information which is available to NESB communities concerning available services, 
what they offer, how to gain access to them, and so on. Translation of a few 
pamphlets into the major community languages is a wholly inadequate response 
to this issue, particularly for elderly members of such communities (and others)
 who may be, illiterate in their own language.45 

Clearly, the provision of appropriate written material is only one of the 
strategies needed to make preventive treatment more accessible: 

Information is a vital part in any service establishment and delivery. The 
effectiveness, utilisation and access of the service by the consumer depends
 on appropriate, accurate...promotion and prevention education...and [the use of] 
appropriate avenues to reach vulnerable groups in the community.46 

For people not fluent in English, or unfamiliar with the Australian health 
system, it can be extremely difficult to obtain medical treatment or intervention 
before an illness becomes acute: 

The two major points of contact for information seem to be Migrant Resource Centres
 (MRCs) and local general practitioners. If MRCs are unaware of the services in 
mental health available in their area, or unfamiliar with mental illness and the 
mental health system, then there will be no, or inappropriate, referrals from them. 
Similarly, if GPs do not link up with local services who can provide for a NESB 
client, then there will be difficulties.47 

In Tasmania the Inquiry was told that many people from non-English speaking 
backgrounds use Migrant Resource Centres as a 'last resort'.48 In Victoria 
these issues were also addressed by the Ethnic Communities and Mental Health 
Issues Group of the Victorian Community Managed Mental Health Services 
agency (VICSERV) in its submission: 

Often NESB psychiatrically ill and their families are referred to ethno-specific 
services in the community... Often staff in these ethno-specific services lack 
information and expertise in psychiatry and find they are unable to assist. 
The result for the individuals and their families is an ethno-specific service
 which is culturally relevant and linguistically accessible but which does not meet 
psychiatric needs, while public run or funded psychiatric services may offer 
psychiatric knowledge, but are inaccessible.49 

Lack of Culturally Appropriate Services 

There was unanimity among experts in transcultural and general psychiatry, 
community advocates, ethnic community workers and families directly affected 
that the mainstream psychiatric system is not effectively servicing the needs of 
people from non-English speaking backgrounds. Two major difficulties were 
continually raised in evidence. First, the essentially monocultural nature of the 
Australian medical system and the consequent provision of culturally inappro-

Human Rights and Equal Opportunity Commission Page 733 

priate services to people from non-English speaking backgrounds; and second, 
the use and misuse of interpreters. 

The Inquiry received a great deal of evidence about the standard of treatment 
received once a mentally ill person is referred to public inpatient psychiatric 
services — but much less about utilisation rates prior to referral. There has 
been limited research concerning the frequency with which people from non-
English speaking backgrounds visit general practitioners and community mental 
health centres and whether this is similar to the rest of the Australian 
population. However, evidence and secondary research made available to the 
Inquiry indicates it is not.50 

The few studies that have been undertaken suggest significant differences 
between immigrant and native born Australians in relation to utilisation of 
primary health care and outpatient services. 

In one survey of Turkish people living in Melbourne, researchers found a high 
rate of psychological stress among respondents, but a significant under-
utilisation of the psychiatric services available, including community psychiatric
 clinics,51 and '...admissions of Turkish-born people to state psychiatric hospitals 
occur at two thirds the rate of that for the Australian-born [and] contact with 
community psychiatric clinics occurs at one third the rate of that for the Australian born'.52 

Expert evidence in NSW indicated that 'crisis services are utilised more often 
than preventive services';53 and in Victoria: 

It is clear that in general it is primarily the very disabled who come to the 
attention of psychiatric services... This observation highlights the question of
 what happens to those members of the [NESB] community who may have less severe
disability but have significant psychiatric illness. Are they receiving treatment? 
If so, by whom are they being treated and how effectively? If not, it is likely...
that suffering and morbidity for which there may be effective treatment goes undetected.54 

This may be linked to the comparatively high rates of hospitalisation and 
inpatient care among people from non-English speaking backgrounds. The 
Mental Health Coordinating Council of NSW expressed concern that people 
from non-English speaking backgrounds experience 'significantly longer periods 
of hospitalisation [which is] possibly due to clients being admitted to hospital 
later in the illness' and the disturbing and significant fact that the 'majority
 of admissions are involuntary and/or escorted by police'.55 

Page 734 Mental Illness Inquiry 

Diagnostic Issues 

There are few assessment and treatment programs designed to meet the 
particular needs of ethnic minority groups. The importance of cross-cultural 
awareness on the part of psychiatrists and other mental health professionals was 
emphasised by the Federation of Ethnic Communities Councils of Australia in 
its submission to the Inquiry: 

The ethnic background of consumers must be considered in the...diagnosis and 
management of mental disorder... [In] the absence of this consideration, diagnostic 
error occurs which leads to inappropriate treatment, prolongation of illness and 
development of chronicity and disability.56 

Evidence to the Inquiry indicated that diagnostic error and inappropriate 
treatment frequently occur. The most common diagnostic errors made by 
psychiatrists treating people from non-English speaking backgrounds relate to 
misdiagnosis of the nature of the illness and diagnosis of psychopathology when 
it is not present. 

Dr Bernardi told the Inquiry that overassessment and inaccurate assessment of 
symptoms often occur because of a clinician's lack of understanding of other 
cultures. She recounted, as one example, the history of an Italian man who had 
sustained a head injury in a car accident. The man was suffering from 
concussion and was brought into casualty. When he recovered consciousness 
he was disoriented and believed that the sedative he was being given was 
poison. The medical staff took this to indicate paranoid behaviour and certified 
the man. However: 

He happened to catch an Italian speaking psychiatrist... [an] interview in his own 
language [resulted in diagnosis of] an organic condition... He received some 
medication and was immediately discharged... [He recovered fully] within a few weeks.57 

The ethnocentricity of psychiatrists was raised by several interpreters who gave 
evidence to the Inquiry. One interpreter and welfare worker told the Inquiry of 
several cases where patients' rights were infringed as a result of a misdiagnosis 
resulting from poor communication: 

A person presented at the hospital behaving strangely... No interpreter was called 
[and] no cultural background information was sought... The patient was there for 
six months until [an ethnic community worker contacted the family]... Communication
 was improved and things were clarified... The person was discharged because it 
was recognised that he did not have a mental illness but an alcohol problem.58 

Human Rights and Equal Opportunity Commission Page 735 

The Inquiry also heard that the diagnostic tools used by psychiatrists to evaluate
 the psychological state of patients can, because of their inherent cultural bias,
be entirely inappropriate for people from non-English speaking backgrounds. 

In tests and diagnostic concepts such as the DSM-III-R59...concepts are devised and
 questions formulated to gauge a standard response... These standards are derived 
from the normal response of the population sample [which is frequently Anglo-Celtic].60 

A number of witnesses said they were concerned about the application of 
culturally inappropriate tests. One example concerned a psychiatrist who was 
administering a test to determine the cognitive ability of a newly arrived 
migrant. One of the questions was, 'Who is the Prime Minister of Australia ?' 
In this witness's view, 'this test had no cultural sensitivity at all'.61 In another 
case, an interpreter had to help administer a word association test to a Southern
 European woman who became increasingly agitated: 

She said to me in her own language, 'What is he doing? Is he mocking me?' She 
[was very] distressed... The woman said she was not a child and she was not 
going to do this test. [Afterwards]...I explained to the doctor that some tests 
are unknown to people from different cultural backgrounds and they may view them 
with suspicion... [The doctor] was not interested.62 

The validity of standard diagnostic tools such as the DSM-III-R was also 
questioned by expert witnesses. There is considerable debate in professional 
circles about whether it is appropriate for psychiatrists to use Western based, 
biological models to diagnose mental illness in people from non-Western 
cultures. 

The therapist, according to this view, is expected to 'deculturalise' the 
presenting symptoms in order to arrive at an objective diagnosis in which a 
biological base is implicit... Such an orientation makes it difficult to diagnose 
[people from non-Western cultures]...who necessarily perceive stress from the 
perspective of their own cultures... The rationale behind DSM-III-R assumes that 
indicators of dysfunction are uniform and universal. It fails to take into account
 illness behaviour which is imbued with cultural symbols, values and beliefs.63 

The Inquiry was told that very few Australian psychiatrists have the necessary 
expertise to take account of cross-cultural values and beliefs when making a 
diagnosis. They often rely on bio-medical models of illness and misdiagnoses 
are consequently made. For example, many people from non-English speaking 
backgrounds refer to 'hearing voices' and 'talking to God'.64 While some 
individuals experience auditory hallucinations as a result of psychosis, 
it should also be recognised that many people from Southern European cultures are 
extremely devout and would certainly find solace in times of stress by 
communicating (sometimes audibly) with God. A psychiatrist failing to take 

Page 736 Mental Illness Inquiry 

adequate account of these cultural 'nuances' could find it difficult to
 differentiate between normal and psychotic behaviour. 

The Inquiry also heard evidence that individuals from particular cultural 
backgrounds are more likely to exhibit physical symptoms as a result of 
psychiatric disorder or psychological distress.65 This process, known as 
somatisation, can complicate diagnosis: 

Applying the DSM-III-R classification to non-Western patients in a textbook 
fashion may not only produce misleading diagnoses but may also neglect other 
valuable behavioural and situational variables and observations that might 
shed light on the patient's emotional condition.6* 

Lack of awareness by clinicians can lead to inappropriate diagnosis and the 
infringement of patients' rights. For example, women from non-English 
speaking backgrounds are sometimes misdiagnosed as suffering from a mental 
illness when overmedication or family problems may be the real problem: 

Many migrant women come to see me with a long history of depression which has
 been treated with benzodiazepines. They are now dependent on drugs...[and have
 come to expect] that this is their lot in life... They may be victims of 
domestic abuse, but because of cultural factors will not tell a male 
practitioner... They are treated as being a sick person rather than the family
 being the problem... [As a result] they are admitted to hospital inappropriately.67 

Use of Interpreters in Hospitals 

The failure of psychiatric services to adequately provide for the linguistic 
and cultural needs [of NESB patients] affects the ability of individuals and 
their families to.. .participate in decision making about their own psychiatric
 treatment. They are effectively disenfranchised.68 

These problems are most apparent when people from non-English speaking 
background are admitted to hospital. Here, the medical model may exclude any 
consideration of the individual's 'values, aspirations, needs and personal 
experiences' and the cultural context in which they have developed.69 As a 
result, hospitalisation can exacerbate the trauma experienced by non-English 
speaking patients because it increases the sense of alienation and distress 
associated with their illness.70 

It is impossible to ensure that non-English speaking patients are aware of their 
rights and understand the nature of their treatment when psychiatrists and other 
hospital staff do not know when or how to use interpreters: 

The failure to provide practice guidelines for professionals across services 
indicating how to use [interpreter services] and when it is necessary or appropriate 
results in the onus for 

Human Rights and Equal Opportunity Commission Page 737 


requesting [them] being placed on the NESB individual and/or family, or an 
interested staff member. The result may be that an individual who requires 
interpreter services to understand the psychiatric illness and the service system 
does not receive this information.71 

Leaving the decision of whether and when to use an interpreter to the discretion 
of medical staff can lead to difficulties. For example, a person may be admitted 
in an emergency situation, making it difficult for hospital staff to obtain a 
detailed case history or to assess their proficiency in English. As a result, it 
may not be until treatment has commenced that it becomes apparent the patient 
does not understand what is happening. 

One witness told the Inquiry of an individual who had been in hospital for four 
months without seeing an interpreter. Medication was prescribed and the patient 
developed an allergic reaction which he could have foreshadowed if staff had 
used an interpreter to communicate with him. In another case, a patient 
received ECT: 

[No prior explanation was given]... This person did not speak any English, 
had no interpreter and was totally terrified [about] the whole situation.72 

The Inquiry frequently heard evidence that psychiatrists and nurses use other 
inpatients, family members and cleaners to interpret.73 Not only does this 
violate principles of privacy and confidentiality, but it may also mean that 
important decisions are based on inaccurate information — sometimes with life-
threatening results. 

Interpreters clearly have a crucial role to play in the treatment process by 
bridging the communication gap between patient and clinician. However, the 
issue is complex and needs to be carefully handled. While qualified interpreters 
are proficient in translation and communication, their skills may not include 
familiarity with mental health terminology and other specialised psychiatric 
issues. One expert told the Inquiry that clinicians tend to oversimplify the 
issues involved in treating people from non-English speaking backgrounds: 

All the efforts in providing services for people from non-English speaking backgrounds
 have been directed towards language... Nobody denies the need to understand the
 [patient] on a verbal level... But it has been repeatedly pointed out in the 
international psychiatric literature that with the use of interpreters.. .
numbers of phenomena which could be relevant for understanding the mental 
illness [are not picked up].74 

Clearly, interpreters need special training to work effectively with people 
affected by mental illness. 

Page 738 Mental Illness Inquiry 

The presence of an inappropriate interpreter — no matter how proficient their 
linguistic skills — can actually inhibit the development of a trusting client-
patient relationship. The Inquiry was told that patients from non-English 
speaking backgrounds will sometimes refuse to have an interpreter present 
during consultations because they know the individual concerned: 

When it comes to very small communities it's almost impossible to get an anonymous 
interpreter, almost inevitably the interpreter will know the patient and vice versa... 
The patients perceive that there will be talk in the community about their case.75 

Treatment Issues 

The evidence indicated that although many non-English speaking consumers 
receive drug treatment, many do not understand the nature of their illness and 
why a particular course of treatment is being prescribed. The Mental Health 
Coordinating Council of NSW documented the case of a person who had been 
receiving treatment for schizophrenia for several years but was unaware of his 
condition until a doctor who spoke his language explained what schizophrenia 
was. As the Council noted (perhaps optimistically): 

It is virtually inconceivable that an English speaking person would receive
 treatment for a long period of time without fully understanding the illness.76 

The Inquiry conducted a telephone survey to obtain additional information about 
the experiences of consumers from non-English speaking backgrounds.77 
Responses revealed that many people who had received drug treatment had not 
been adequately informed about the nature of their mental illness and the type 
and side effects of the drugs prescribed. One consumer told the Inquiry he had 
been seeing private psychiatrists and taking medication for several years, but 
only discovered that he was being treated for schizophrenia when he saw his 
chart during a period in hospital. Others expressed concern that they had never 
been offered alternatives to drug based treatment or information about 
community support services. 

This evidence is supported by recent research which indicates that people from 
non-English speaking backgrounds are more likely to receive treatment with 
drugs and ECT, and less likely to receive psychotherapy, group therapy and 
occupational therapy — even where these may be more appropriate for their 
particular conditions.78 

Another recent study of the case records of 185 Turkish patients referred to a 
bilingual psychiatric service, revealed that a significant proportion had been 
receiving inappropriate drug treatment. The patients were suffering from 

Human Rights and Equal Opportunity Commission Page 739 

situational reaction, neurotic disorder, schizophrenia and paranoid psychosis, 
psychotic depression and mania. The researchers concluded that 

...drug treatment was common, regardless of diagnosis and there was a poor match 
between diagnostic category and the classes of drugs which patients were receiving,
 suggesting that treatment with inappropriate classes of drugs was not uncommon.79 

Community organisations also expressed concern about the over-reliance on 
drug-based treatment programs: 

Many of the NESB psychiatrically ill are effectively shut out from receiving 
many non-pharmacological rehabilitation and treatment services both in institutional
 and community 
settings.80 

The Inquiry heard several explanations for this over-emphasis on drug 
treatment. First, people from non-English speaking backgrounds are more likely 
to receive treatment in the chronic stage of an illness when medication is 
necessary. Second, language differences between patient and clinician make 
misdiagnosis and inappropriate treatment more likely. Finally, people from non-
English speaking backgrounds may be unwilling to participate in psychosocial 
therapies because they are culturally unfamiliar. 

However, expert evidence to the Inquiry indicated that people from non-English 
speaking backgrounds are often forced to comply with treatment approaches and 
therapies that are anathema to their cultural background and values.81 It was 
suggested that the only way to meet these needs is to develop more holistic 
treatment strategies which are closely linked into local communities: 

The psychiatric hospital is something extremely important. However, I believe that
 the accent on the distribution of resources and organisation of services has to be 
on community oriented psychiatry... The non-English speaking background patient has
 to have the support of their community.82 

Continuity of Care 

People from non-English speaking backgrounds experience particular problems 
in obtaining continuity of care. Ethnic organisations and communities generally 
do not have the resources to provide community support to people with 
psychiatric illness and their families once they have been discharged from 
hospital.83 

A matter for particular concern, given the major shift to community-based psychiatric
 services, is that community-based services are particularly under-used by immigrant
 communities. In this case, a shift to community-based services, which may be expected
 to lead to considerable benefits for the general community, may, paradoxically, lead to a 

Page 740 Mental Illness Inquiry 

further reduction in service use by immigrant communities, who may have a greater
 need for services. It is not possible to predict such difficulties and to prevent
 unintended consequences of service change without information such as can be derived 
from service utilisation data.84 

In Victoria, the Inquiry was told that 'there is a significant population making 
use of psychiatric inpatient and outpatient facilities, but is receiving very little
 in terms of other [community based] services'.85 In the 1989-90 financial year, 20 
percent of the individuals discharged from psychiatric inpatient services in Victoria
 were from non-English speaking backgrounds.86 While discharge data reflects a high 
utilisation rate of inpatient services, there is no information available about the 
extent to which people from non-English speaking backgrounds use community based 
programs and community managed services 
once they leave hospital.87 

The under-utilisation of community based psychiatric services is often a 
function of poor or non-existent discharge planning. The Inquiry was told by 
an organisation representing the large Greek community in Melbourne that 
patients are often discharged into the community with no support networks or 
structured plans for continuing care.88 This was echoed by other Victorian 
witnesses: 

Unfortunately NESB communities have not had information and have not participated 
in the debate or the processes involved in deinstitutionalisation. This has meant
a generally poor understanding of the psychiatric service system...and the support 
and rehabilitation options available.89 

In the absence of information about alternatives to hospital based care, many 
consumers from non-English speaking backgrounds and their families are 
unable to lobby for services and initiate change. Instead, they continue to care 
for the mentally ill at home, and utilise inpatient facilities sporadically. 

In many respects people of NESB [non-English speaking background] who are mentally 
ill share similar objectives to people of ESB [English speaking background] 
in their use of psychiatric services. 

What is Required? 

NESB issues have been addressed by governments at all levels over the last ten years —
 the Federal program of 'Access and Equity' has been in place for some time, and its
 title is synonymous with the major problems facing people of NESB... Equal opportunity 
practices and anti-discrimination legislation have gone a long way to removing visible
 barriers to employment, accessing services and quality of life. What is left now, 
however, is the task of remodelling services in the community at the grass roots 
level, in order to make them appropriate and accessible.90 

Human Rights and Equal Opportunity Commission Page 741 

The Need for Culturally Appropriate Services 

Fundamental problems contributing to inadequate mental health care models include a 
lack of easily accessible translating services, lack of cross-cultural education 
in psychiatry for mental health workers and poor working relationships with ethno-
specific non-government organisations resulting in inappropriate referrals, and poor
 collaboration and consultation.91 

Evidence to the Inquiry established that people from non-English speaking 
backgrounds often experience infringements of their human rights as a result 
of culturally inappropriate services and insensitivity or ignorance on the part of
 psychiatrists and other mental health professionals. There appears to be a 
mistaken perception on the part of some policy planners and service providers 
that the particular needs of non-English speaking consumers can be adequately 
met by the mainstream services currently available. This is clearly not the case. 

Many of the inadequacies in services currently available relate to the fact that 
diagnosis and treatment of psychiatric disorders are firmly based on Western 
definitions of mental illness and the medical model. Service providers must 
develop a more comprehensive approach to these issues and to examine ways 
in which cross-cultural perspectives can be introduced into the clinical setting. 

A major area of concern for many groups representing non-English speaking 
people is the absence of consumer participation in decision-making and 
planning. It was suggested to the Inquiry that simple but important strategies 
for overcoming the ethnocentric nature of mainstream services include the 
employment of bilingual and bicultural psychiatrists and mental health workers 
and the development of language skills among health professionals treating 
NESB people with psychiatric disabilities. Related to this is the demonstrated 
requirement for more stringent guidelines for the use of interpreters. 

The evidence presented clearly established that misdiagnosis and inappropriate 
treatment of non-English speaking consumers could have been prevented in 
many circumstances by better communication with clients. Training in the role 
of interpreters in the clinical process and the use of interpreters and ethno-specific
 agencies would be valuable for many mental health professionals. In 
addition, the introduction of standard procedures in public psychiatric hospitals
 could include the use of interpreters at key stages, including admission, the 
period following admission when decisions about treatment are being made, during 
pre-discharge planning (of which there is currently precious little) and at the 
point of discharge. 

The evidence also demonstrated that mainstream services are often unaware of 
the demographics of their client groups. Understanding the demographic profile 

Page 742 Mental Illness Inquiry 

of the ethnic groups living within an area would allow local service providers 
to target their resources and outreach strategies to particular communities. 
Similarly, improved liaison and information-sharing with ethno-specific non-
Government agencies would facilitate client involvement in policy development 
and planning and encourage a more informed understanding of the needs of 
particular client groups. It would also encourage the use of community-based 
mental health centres and other alternatives to hospital treatment. 

The Inquiry heard that one of the main impediments to successful service 
provision is the lack of coordination between government, non-government and 
ethno-specific agencies in relation to the planning, implementation and 
evaluation of services: 

[The failure to coordinate policy development].. .only increases the probability 
that services relevant to NESB people and their families will be developed in an
 ad hoc manner and not integrated within all service delivery areas. The result 
is uncertainty of access to relevant services for NESB people, fragmented and 
generally inadequate delivery.92 

The provision of adequate funding is obviously a significant element in the 
development of culturally appropriate mental health services. Several 
psychiatrists told the Inquiry that they acknowledged the need for specialist 
services, but simply could not provide for them from existing resources: 

We are under-resourced [and that] means that we have even more difficulty in trying
 to provide for the niche requirements for the different NESB groups. I think this
 is a problem.93 

Several specialist services are currently operating in Australia for migrants 
suffering psychiatric illness as a result of torture and trauma. However, their 
activities are also threatened by insufficient funding. 

A number of witnesses suggested that one positive way of addressing these problems
 was to fund more joint projects between the community and government sectors: 

[One problem has been] the difficulty in initiating collaborative pilot projects
 between government and non-government organisations... A key area of concern is
 looking at the collaboration between government and non-government organisations
 regarding new innovations, [to] target people from non-English speaking backgrounds.94 

Transcultural Psychiatric Models 

While there are few services designed to meet the special needs of people from 
non-English speaking backgrounds in Australia, the Inquiry did receive 

Human Rights and Equal Opportunity Commission Page 743 

evidence concerning two specialist facilities: the Multicultural Psychiatric 
Centre in Perth, and the Transcultural Psychiatry Unit in Melbourne. 

Both centres operate along the following lines: 

In essence, [transcultural psychiatry] challenges the Western frame of reference
 within which disease is understood and treated. It basically questions the view 
that signs and symptoms of behaviour are logically of the same order in different
 cultures. As a result of this new thinking we have begun to question the taken-for
-granted assumptions of psychiatric theorising such as those relating to the 
normal/abnormal, validity of diagnostic categories, assumptions about modes of treatment.. .95 

The Multicultural Psychiatric Centre 

The Multicultural Psychiatric Centre was established by the Health Department 
of Western Australia in 1983. The Centre's underlying philosophy is holistic: 

The individual with psychological/psychiatric problems, from whatever background,
 should be seen and understood as a total human being and not as an admixture 
only of symptoms or social problems or cultural peculiarities.96 

The Centre is community-based, and provides specific clinical psychiatric 
services as well as a range of psychosocial therapies. It employs a
 multidisciplinary team of psychiatrists, psychiatric nurses, psychologists 
and social workers. At the time of writing 13-15 permanent staff were employed. 

The Centre strives to care for patients in the community wherever possible. It 
runs a comprehensive outpatient service for people from non-English speaking 
backgrounds, providing consultations at the Centre itself, as well as consultations
 in patients' homes, hospital wards and nursing homes as necessary. 
Community psychiatric nurses make home visits, monitor medication use and 
provide crisis intervention services. 

The Centre is concerned with better understanding the relationship between 
culture and mental illness, and the delivery of psychiatric services in a 
multicultural society. Clinical services are supplemented by a range of 
educational and therapeutic activities, including welfare services and living 
skills for clients, and practical advice and assistance in relation to accommodation, 
employment and financial and legal issues. In addition to these services, the centre 
is involved in providing professional education in transcultural psychiatry for
 psychiatrists and other mental health workers — including assistance with 
clinical advice on a case by case basis. 

Page 744 Mental Illness Inquiry 

While the Centre has been the subject of criticism because it does not provide 
a 'mainstream' service, the Inquiry was told that: 

Services like the Multicultural Centre are mainstreaming. First, because they
 respond to the needs of the society; secondly, they provide people with the 
opportunity to receive services and assistance from people who know their
 culture... Thirdly, they are in the mainstream because through their activities
...they spread their ideas to other services. Finally, they are in the mainstream 
because they do not work in isolation.97 

From this perspective, services like the Centre can be seen as supplementing 
and broadening the mainstream psychiatric system by providing a cross-cultural 
approach which is not yet generally available. NESB consumers are able to 
obtain integrated care within the community which incorporates preventive 
education and information, as well as appropriate medical treatment when 
necessary. 

The Transcultural Psychiatry Unit 

Victoria's Transcultural Psychiatry Unit acts as an adviser to the Office of 
Psychiatric Services. It attempts to ensure that psychiatric services become 
more accessible and effective in catering to the needs of people from non-
English speaking backgrounds. It undertakes work in four areas: research, 
education, clinical services and policy development. 

The Unit provides a bilingual clinical service, using interpreters specialised 
in psychiatric and medical terminology who are able to assist medical staff when 
assessing non-English speaking patients. It is also responsible for providing 
interpreter services for the State psychiatric service and for conducting 
continuing education for medical undergraduates, psychiatric registrars, nurses 
and other health workers on cross-cultural issues. 

In order to improve the effectiveness of mainstream services, the Unit has 
undertaken a number of research projects to assess the prevalence of psychiatric 
disorder in ethnic communities, patterns of service utilisation, and the role of 
culture in the conception of mental health and the treatment of mental illness. 
The research agenda is primarily concerned with obtaining the information 
needed to inform mental health policy development and implementation for 
immigrant communities. 

The Need For Further Research 

One of the major obstacles to improving services to people from non-English 
speaking backgrounds is the lack of information available on the prevalence of 

Human Rights and Equal Opportunity Commission Page 745 

mental illness generally, and the particular kinds of psychiatric disorder which 
occur in different non-English speaking communities. As one expert put it: 

Any attempt to understand and to rectify disadvantage based on language and culture must 
attend to relevant factors in the NESB communities and in mental health services and 
practices. Of particular importance is the grossly inadequate level of research in the 
area of defining mental health needs of NESB communities, in the investigation of the 
appropriateness and effectiveness of educational service systems, and in the development
 of service models and treatment approaches which are responsive to identified mental
 health care needs.98 

Consumer groups and community workers expressed similar concerns. The 
Ethnic Issues Group of VICSERV recommended that: 

Both the State and non-government sector agencies become more active in the collection 
and analysis of data regarding psychiatric services requirements and current service 
utilisation by NESB communities, and that this information be actively utilised in the
 development and provision of psychiatric services.99 

The Inquiry supports this recommendation. The evidence summarised in this 
chapter clearly demonstrates the need for basic data collection on the ethnicity 
of client groups and rates of service utilisation — data which can be used to 
undertake needs analysis and assessment. It also illustrates the value of research on the
 incidence of mental illness in particular ethnic communities, as well as broader studies 
of issues relating to mental health and illness among the NESB population generally. 

The Need for Education 

The Inquiry was told there is a critical need for professional education of 
psychiatrists and other mental health professionals in cross-cultural issues. 
Several expert witnesses emphasised that cross-cultural awareness is often 
treated superficially by medical professionals and that this lack of commitment 
has to be addressed to ensure effective service provision:100 

I want to make a special point about education. Education...particularly regarding ethnic services
...[is often reduced to] folkloristic [stereotypes]... The Italians like spaghetti...and the 
Chinese are afraid of spirits... Education...has to be meaningful...[not only] at the level of 
services but as part and parcel of the university curricula for people who work in the field of
 mental health, be those people social workers, sociologists or doctors... We cannot go off 
and claim that we have met our responsibilities regarding the education of people 
with a couple of lectures on how [a particular ethnic group] behaves or a couple of lectures on 
migrants and mental health.101 

Other evidence to the Inquiry supported these observations. Consumer 
organisations stressed the provision of continuing education for government and 

Page 746 Mental Illness Inquiry 

non-government mental health workers as essential. Training for non-medical 
staff working in ethno-specific agencies in psychiatric issues and medical 
terminology was seen as a simple and effective way of reducing inappropriate 
referrals and increasing general awareness of mental health issues. 

Consumer education also needs to be given higher priority: 

Basically...a lot of people from non-English speaking backgrounds don't have a very good understanding
 of their rights as consumers... The care-givers of those people don't really know what the rights 
of their relatives are either.102 

Community education must also be complemented by effective outreach 
programs which target non-English speaking communities: 

The outreach model...is much more satisfactory in meeting the needs of non-English speaking communities 
because in a sense you're reaching the whole community as well as the individual.103 

Many public awareness campaigns and preventive strategies never reach non-
English speaking communities because they are inappropriately targeted. 
Coordination with ethno-specific agencies and the media when planning 
activities (for example, Mental Health Week and other national public events) 
would help to address this problem — as would the active involvement of peak 
consumer organisations in bilingual and cross-cultural groups to support people 
from non-English speaking backgrounds with mental illness. 

Human Rights and Equal Opportunity Commission Page 747 


1. Dr Elsa Bernardi, representative, RANZCP, NSW Branch. Oral evidence, Sydney 
17.6.91, pill. 
2. Bureau of Immigration Research, Community Profiles: Non-English Speaking Born, AGPS,
 Canberra 1991. These figures are derived from 1986 Census statistics. 
3. H Minas, Transcultural Psychiatry Papers, Victorian Transcultural Psychiatry Unit, vl, Dec 1991, p31. 
4. ibid, p32. 
5. See, for example, L Jayasuriya, D Sang, and A Fielding, Ethnicity, Immigration and 
Mental Illness: A Critical Review of Australian Research, Bureau of Immigration Research, AGPS, Canberra 1992, pplO-11. 
6. Bernardi, op cit, pl09. 
7. O'Brien, op cit, pp277-278. 
8. Jayasuriya et al, op cit, p47. 
9. Margaret Cunningham, NSW Service for the Treatment and Rehabilitation of Torture and 
Trauma Survivors (STARTTS). Oral evidence, Sydney 20.6.91, p438. 
10. Margaret Cunningham and Rise Becker, STARTTS. Submission, pi. Recent research supports 
this estimate, suggesting that the figure may be significantly higher: Patrick McGorry, 
'The significance of torture: Theoretical and therapeutic aspects', in H Minas (ed), 
Cultural Diversity and Mental Health, Proceedings of the 14th Annual Symposium of the
 Section of Social and Cultural Psychiatry, RANZCP, Melbourne 1991, pl65. 
11. Professor Derek Silove, Professor of Psychiatry, University of NSW and Director, Mental 
Health Services, South Western Sydney Area Health Service and Macquarie Clinic, Liverpool Hospital.
 Oral evidence, Sydney 21.6.91, p572. 
12. G Andrews, 'The Anxiety Disorders', in P Beumont and R Hampshire (eds), Textbook of 
Psychiatry, Blackwell Scientific Publications, Melbourne 1989, plOl. 
13. Dr Aidene Urquhart, Director of Child Psychiatry and Clinical Coordinator, Mater Children's 
Hospital, Brisbane. Oral evidence, Brisbane 16.8.91, pl685. 
14. Cunningham and Becker, op cit, pi. 
15. id. 
16. Silove, op cit, pp574-575. 
17. 'The.four month siege of Sarajevo, with its daily mayhem and systematic destruction, has 
spawned a type of mental illness that psychiatrists are at a loss to treat... [Sufferers] show 
symptoms of severe depression. But they do not respond to standard treatment for depression'. 
Allen Nacheman, 'A war-ravaged people willing themselves to die', Weekend Australian, 5-6 September 1992. 
18. D Ames, 'Geriatric Psychiatry in a Culturally Diverse Society', in I H Minas (ed), Cultural
 Diversity and Mental Health, op cit, pi 19. 
19. Bernardi, op cit, pi 10. 
20. Dr Slav Kostov, senior consultant psychiatrist, Multicultural Psychiatric Centre. Oral evidence,
 Perth 11.2.92, pl76. 
21. ZophiaPakulski, HACC project worker, Migrant Resource Centre. Oral evidence, Hobart 13.11.91, p284. 
22. ibid, pp282-286. 
23. ibid, p285. 
24. Bernardi, op cit, pi 10. 

Page 748 Mental Illness Inquiry 

25. Pakulski, op cit, p286. 
26. J Woodruff, Director, NSW Women's Coordination Unit. Submission, pi. 
27. Robyn James, Western Region Women's Human Rights Commission Response, NSW. 
Submission pl5. 
28. Joint submission to the Inquiry Action on Disability within Ethnic Communities (ADEC) and 
the Greek Welfare Society, pp8-12. Also Kostov, op cit, pl73. 
29. Study quoted in Jayasuriya et al, op cit, p27. 
30. Vivi Germanos-Koutsounadis, Director, NSW Ethnic Child Care Development Unit, Response to 
the Report of the Mental Health Task Force to the Overarching Committee on Health and Aged Care 
and to the Australian Health Ministers Advisory Council, p8. Also see joint ADEC/Greek Welfare 
Society submission, op cit, p3, which calls for the establishment of support groups for NESB 
carers, particularly women. 
31. Eva-Kersti Holmes, Launceston Migrant Resource Centre, Tasmania. Submission, pi. 
32. Vittoria Mancini, Ethnic Communities and Mental Health Issues Group of the Victorian 
Community Managed Mental Health Services Inc (VICSERV). Submission, pi. 
33. See ADEC submission, op cit, and submission by Dr Harry Minas, Director of the 
Victorian Transcultural Psychiatry Unit, p2. 
34. Kostov, op cit, pl71. 
35. Bernardi, op cit, pi 12. 
36. ibid, ppl 11-112. 
37. Anne Wearne, MA thesis, Schizophrenia and the Family: Case Studies of Four Families 
Attending the Multicultural Psychiatric Clinic. Submitted to the Inquiry. 
38. ibid, p67. 
39. The term 'somatisation' usually refers to the development of physical symptoms as a 
manifestation of psychological disturbance or mental illness. 
40. Wearne, op cit, pp67-68. 
41. L Cole-Edelstein, 'Mental Health Services and NESB', Mental Health Coordinating Council 
Inc, Spotlight on Mental Health, pi. 
42. Eileen O'Brien, advocacy worker, Home and Community Care Funded Program, Migrant Resource 
Centre. Oral evidence, Hobart 13.11.91, p279. 
43. Minas, op cit (submission), pp2-4. 
44. Cole-Edelstein, op cit, p2. 
45. Minas, op cit (submission), plO. 
46. Germanos-Koutsounadis, op cit, p5. 
47. Cole-Edelstein, op cit, p6. 
48. Irene Mathews, social worker, Migrant Resource Centre. Oral evidence, Hobart 12.11.91, p288. 
49. Mancini (VICSERV Ethnic Communities and Mental Health Issues Group), op cit, p7. 
50. Gabriel Malageorgiou, Action on Disabilities within Ethnic Communities. Oral evidence, 
Melbourne 9.4.91, pp317-319. 
51. Cited in H Minas, Transcultural Psychiatry Papers, op cit, vl, p45. 
52. ibid, p46. 
53. Bernardi, op cit, p111. 
Human Rights and Equal Opportunity Commission Page 

749 

54. H Minas, Transcultural Psychiatry Papers, op cit, vIII, p356. 
55. Cole-Edelstein, op cit, p3. 
56. C Harbaum, Federation of Ethnic Communities Councils of Australia. Submission, pi. 
57. Bernardi, op cit, pi 12. 
58. Maria Graham, welfare worker, Inala Community House. Oral evidence, Brisbane 
14.8.91, pl762. 
59. Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised. (As discussed 
in Chapter 3, this manual is one of the standard diagnostic texts for psychiatric disorders.) 
60. Pat Dudgeon, Head, Centre for Aboriginal Studies, Curtin University. Oral evidence, 
Perth 12.2.92, p307. 
61. Graham, op cit, pl762. 
62. Stella Goiser, Tasmania. Submission, ppl-2. 
63. A Nikelly, 'Can DSM-IIIR be used in the diagnosis of non-Western patients?', 
International Journal of Mental Health v21 Nol, p4. 
64. Bernardi, op cit, pplll-114. Wearne, op cit, also discusses these issues. 
65. For example, a study cited by Anne Wearne notes that 71 percent of clients attending a 
psychiatrist in Taiwan exhibited somatic symptoms. 
66. Nikelly, op cit, pl6. 
67. Bernardi, op cit, pi 13. 
68. Mancini (VICSERV), op cit, p4. Similar concerns were also expressed by the Federation of 
Ethnic Communities Councils of Australia. 
69. Rostov, op cit, pl71. 
70. ibid, ppl71-173. 
71. Mancini (VICSERV), op cit, p9. 
72. Graham, op cit, pl761. 
73. Marie Gibson, Coordinator, Migrant Resource Centre, Townsville. Oral evidence, Townsville
12.8.91, pi 137; Graham, op cit, pl764; and Mathews, op cit, p282. 
74. Rostov, op cit, pl72. 
75. Lisbet Castro Lopo, Acting Area Coordinator, Migrant Health Services, Hunter Area 
Health Service. Oral evidence, Newcastle 9.7.91, p808. 
76. Cole-Edelstein, op cit. 
77. The telephone survey was conducted on 30-31 August 1991 with the assistance of the 
NSW Mental Health Coordinating Council. It aimed to obtain further evidence from individuals
who believed that they, or someone known to them, had suffered discrimination or a violation 
of their rights due to mental illness. Flyers were distributed throughout NSW inviting people
 to call a toll-free number and provide their information anonymously. Over 200 calls were 
received. Of those, 32 calls were received from people of non-English speaking background.
 In addition to concerns relating to inappropriate drug treatment, callers raised the 
following issues: the lack of information available about community-based and other 
mental health services; inappropriate treatment and referrals made by GPs; and the lack 
of information regarding patient rights. 
78. Minas, op cit (submission), plO. 

Page 750 Mental Illness Inquiry 

79. H Minas, Transcultural Psychiatry Papers op cit, (v)i, p46. 
80. Mancini (VICSERV), op cit, p6. 
81. Kostov, op cit, pp 172-173. See also submission by the Federation of Ethnic 
Communities Councils of Australia. 
82. Kostov, op cit. 
83. Mancini (VICSERV), op cit, p7. 
84. Minas, op cit (submission), p9. 
85. Malageorgiou, op cit, pp317-318. 
86. ibid, p317. 
87. id. 
88. Action on Disabilities within EthnicCouncil, Victoria, op cit, pp8-9. 
89. Mancini (VICSERV), op cit, p7. 
90. Cole-Edelstein, op cit, pi. Communities (ADEC) and the Greek Welfare 
91. ADEC and the Greek Welfare Society, op cit, pl2. 
92. Mancini (VICSERV), op cit, p6. 
93. Dr Roger Gurr, Clinical Director of Psychiatry, Blacktown Community Health Centre.
 Oral evidence, Sydney 17.6.91, p77. 
94. Malageorgiou, op cit, p323. 
95. L Jayasuriya, Multicultural Australia: Towards the Twenty-First Century, paper 
presented at the Twelfth Annual Conference of the Federation of Ethnic Communities Councils, August 1991. 
96. Multicultural Psychiatric Centre, Education Program 1990, p2. 
97. Kostov, op cit, pl75. 
98. Minas, op cit (submission), p3. 
99. Mancini (VICSERV), op cit, p6. 
100. Kostov, op cit, pl79; Bernardi, op cit, ppll4-115. Also Dr San Pedro, medical
 officer in charge, Migrant Mental Health, NT Department of Health and Community 
Services. Oral evidence, Darwin 21.7.92, pp95-98. 
101. Kostov, op cit. 
102. Malageourgiou, op cit, p322. 
103. ibid, p324. 

Human Rights and Equal Opportunity Commission Page 751 
Chapter 25 

FORENSIC PATIENTS AND PRISONERS 

Untreated people are ending up in jail through either misunderstanding, non-recognition 
of their symptoms, or as a direct result of actions emanating from their treatable 
conditions going untreated. Once in jail, clearly, their opportunities to receive
 access to treatment and services are even more diminished.' 

Definitions 

This chapter addresses issues affecting mentally ill people who commit criminal 
offences, and those who are or have been in the custody of police or prison 
services. The two criteria do not necessarily describe the same group of people. 
For example, some offenders serve their sentences in psychiatric wards; others 
receive a non-custodial sentence such as a community service order. Many 
inmates in jail are not actually serving a sentence; they are on remand, awaiting a
 court hearing. And former prisoners, whether released unconditionally or on parole,
 face an array of daunting obstacles in living with mental illness. 

Prison conditions, police practices and the criminal justice process are all 
important areas to examine in assessing any society's attitude to human rights. 
As evidence already outlined has clearly established, people affected by mental 
illness are especially vulnerable to abuse or denial of their rights. 

'Forensic Patients' 

Legally, 'forensic patients' are people whose status in the penal system is 
determined by a mental illness2 — eg offenders whom the court finds unfit to 
stand trial. 

However, mental health professionals use the term 'forensic patient' to refer to 
any prisoner receiving psychiatric treatment, whether or not that fact has been 
legally acknowledged. 'Forensic psychiatrists' treat prisoners in jails and 
psychiatric wards, but may also provide some continuing care to ex-prisoners 
living in the community. They also provide psychiatric services to the courts— giving 
expert evidence during trials and preparing reports on particular offenders for 
sentencing judges to take into account. 

Page 752 Mental Illness Inquiry 

Relevant Human Rights Instruments 

As described in Chapter 2, mentally ill people in the criminal justice system 
have rights prescribed in international treaties and other human rights 
instruments. These include the International Covenant on Civil and Political 
Rights (ICCPR); the Convention Against Torture and Other Cruel, Inhuman or 
Degrading Treatment or Punishment; and the Body of Principles for the Protection 
of all Persons under any Form of Detention or Imprisonment. 

The Principles for the Protection of Persons with Mental Illness specifically 
apply to prisoners. Principle 20 stipulates they are entitled to the best available 
mental health care, and to all the rights specified in the Principles, 'with only 
such limited modifications and exceptions as are necessary in the circumstances'. 

In addition, the UN has developed the Standard Minimum Rules for the 
Treatment of Prisoners ('the Standard Minimum Rules'). Australia adopted 
these Rules in the form of the Australian Standard Guidelines for the Treatment 
of Prisoners in 1978. 

Prevalence of Mental Illness Among Prisoners 

What is the prevalence of mental disorder within the prison system is a quite 
different question to the numbers of individuals being treated in the forensic
 psychiatric service.3 

If the rate of mental illness in prison was measured by the number of 
individuals designated 'forensic patients', it would be deceptively low. 
According to the statistics most prison systems have only a small number. For 
example, NSW in October 1991 had 86 prisoners covered by the forensic 
review legislation.4 This was just over 1 percent of the State's prisoners at
 the time.5 Similarly, South Australia's prison psychiatric ward, James Nash 
House, has usually 25 to 30 inmates from the criminal justice system being cared 
for within it. [However,] I suspect the prevalence of mental disorder within the 
prison system is very, very much higher than that.6 

In the general prison population, the prevalence of mental illness is difficult 
to quantify. Most prison services do not routinely assess inmates for psychiatric 
problems, either on arrival or at any time — largely due to a chronic lack of 
funds for health services of any kind.7 

Many people believe that the new approach to mental health since the 1950s has 
resulted in the 'criminalisation' of mental illness: instead of being detained in 

Human Rights and Equal Opportunity Commission Page 753 

hospitals, large numbers of mentally ill people are said to be ending up in 
prison: 

If you decrease the number of mental health system beds, there will be an 
equivalent rise in prison system beds, as those with mental health problems 
will be channelled into the prisons.8 

Empirical research on mental illness in prisoners has been scant and at times 
inconsistent.9 The findings of the main Australian study on the topic indicate 
a high rate of mood disorders in jail, especially major depression: 12 percent 
of subjects had a current diagnosis. A startlingly high proportion of prisoners 
(82 percent) had suffered at least one 'mental disorder' at some point in their 
lives (including alcohol or drug abuse).10 However, the findings do not 
support the perception of a large scale shift from hospitals to jails as the new 
repositories of people with severe psychotic illness.11 

The general belief among witnesses to the Inquiry was that a great deal of 
mental illness goes undiagnosed in jails. This is not only caused by the lack of 
resources: the atmosphere of deprivation and despair which is normal in prisons 
leads staff and inmates to become desensitised to suffering.12 The individuals 
affected may only come to the attention of prison authorities if their behaviour 
becomes severely disruptive. 

Evidence to the Inquiry clearly indicated a higher rate of mental illness and 
disorder in prisons than among the general population.13 A Tasmanian study 
found that approximately one-third of female prisoners admitted over the last 
ten years at Risdon Prison have had a psychiatric history;14 but the absolute 
number with disorders has also steadily increased during that period.15 An 
expert witness in Sydney estimated that 30-50 percent of young people in 
detention facilities have a mental health problem.16 Another said 1-5 percent 
of prisoners have a 'classifiable psychiatric illness, meaning particularly 
psychotic states', while some 20 percent 'exhibit some form of psychological 
distress, symptoms which are troublesome or disabling and for which they 
require treatment or counselling'.17 

NSW is estimated to have 300-400 prisoners who will require psychiatric 
follow-up after release, and another 500-600 currently on parole (but still 
under sentence) who require psychiatric management.18 (300-400 prisoners 
represent 5-7 percent of the State's prison population.) The Schizophrenia 
Fellowship in Queensland estimates there are about 150 people with schizophrenia 
in that State's jails19 (approximately 7 percent), while in the ACT's remand
 centre over half the inmates are 'believed to have a form of mental illness'.20 

Page 754 Mental Illness Inquiry 

In Darwin the Inquiry was told that the population affected by mental illness in 
the Northern Territory includes a particularly high proportion of criminal 
offenders. This is because the NT population profile is young, with about 40 
percent of Territorians under age 25, and offending is most common among 
young people.21 

One obvious indicator of poor mental health is a high suicide rate. In 1990 and 
1991 in Australia, 114 people died in prison or police custody, including at 
least 50 suicides.22 

However, the lack of any systematic data on the mental health of prisoners is 
disturbing:23 

We really don't know at the moment who is there because, to the best of my 
knowledge, there has not been an adequate census. I think one of the first things
 one ought to be doing is having some sort of census, because it really does 
matter whether we are talking about 1 percent or 5 percent.24 

Despite the lack of statistical data, many witnesses told the Inquiry there are 
seriously ill or disordered people in our prisons who should not be there at all. 
Imprisonment damages them personally (by aggravating their condition); it is also 
an inappropriate use of the criminal justice system.25 They basically need 
treatment — not punishment. 

The mental illnesses found in jails include schizophrenia and other psychotic 
disorders (including drug-induced and other 'organic' psychoses), affective 
disorders such as depression, and adjustment disorders.26 Two other disorders 
are not strictly mental illnesses, but nonetheless fall to mental health workers 
to treat: extreme 'personality disorders'27 and substance abuse.28 Many 
prisoners have more than one of these. A severe personality disorder often 
masks an underlying mental illness;29 drug and alcohol abuse are rife.30 The 
Tasmanian study of women prisoners found that, rather than chronic severe 
mental illness, the most common diagnoses are personality disorders and drug 
abuse.31 

Who Are the Mentally Ill Prisoners? 

Evidence to the Inquiry established that mentally ill prisoners have several 
common characteristics which distinguish them from other prisoners: 

[They are] less likely to be in a stable relationship; they are more likely to
 be unemployed; they have fewer children... they have more periods of imprisonment.32 

Human Rights and Equal Opportunity Commission Page 755 

Mentally ill inmates are more likely than other prisoners to be poorly educated; 
many also suffer from learning disabilities or difficulties (such as attention 
deficit disorder) which exacerbate their condition.33 

As for the offences for which they are in prison: 

The nature of their offences is generally minor, although there are major crimes
 committed by those suffering from mental illness. In many cases, mental illness
 has been an important factor in the commission of the offence or alleged offence.34 

Witnesses in the Northern Territory said their forensic services deal with a 
large number of sexual offenders, especially those diagnosed with a personality 
disorder.35 

Legal Recognition of Mental Illness 

Our criminal justice system recognises four ways in which mental illness can 
affect the disposition of offenders. A person charged with a criminal offence 
may be: 

• found unfit to plead, and thus unfit to be tried; 
• tried and acquitted on the grounds of mental illness; 
• convicted, but mental illness is taken into account as relevant to sentencing; 
• diagnosed while in custody — either while serving a sentence or on remand.36 
People who fall into the first two of these categories are often detained 'at the 
Governor's pleasure' — ie indefinitely — either in jail or in a psychiatric ward. 

A fifth category comprises offenders who have a 'personality disorder' but not 
a mental illness. The most publicised prisoner in this category was the late 
Garry David, who was held for three years in preventive detention in Victoria 
after his sentence had expired, notwithstanding that he did not meet the 
legislative definition of 'mental illness'. 

Does Mental Illness Lead to Jail? 

He did hear a voice one morning — he said on the wireless — that told him if he
 could go to jail, he would be cured. So he went around to a used car lot, he
 threw a stone through a window and in sub-degree temperatures — there was ice
 on the ground — he went at 5 o'clock in the morning and sat and waited till 
7am for the police to arrive, whilst we were driving the countryside looking
 for him.37 

Page 756 Mental Illness Inquiry 

Many people are taken into custody — or have their detention prolonged — as 
a direct or indirect consequence of their mental illness or disorder going 
untreated. Untreated mental illness clearly causes some people to behave 
irresponsibly, irrationally and in a bizarre fashion. Sometimes this behaviour 
brings people to the attention of the police; in a small number of instances 
untreated mentally ill people commit violence against others. 

The Inquiry heard several accounts of tragedy resulting from the actions of 
people who were known to be mentally ill, and in fact had been under some 
form of psychiatric care, but without sufficient continuity. One terrible 
example was a young man with long-term schizophrenia who owned firearms; he shot 
four young women dead. He was seeing a private psychiatrist, but was not 
considered critical enough for hospitalisation at the time of the offence: 

The system didn't work then, and the results were the death of four young girls
 with the associated tragedy for their family — but also a tragedy for the young 
man himself... I suspect if he were under a system whereby committal had been 
easier and staying in hospital had been easier, and there had been a firmer 
and more detailed system of control once he was discharged, he would probably
 have had a life which consisted of admissions to hospital and then various 
discharges...whereas now he's likely to be incarcerated until the day he dies.38 

The Inquiry heard many examples of untreated mental illness leading to jail: 

• In [our son's] case the boredom which develops because of lack of activity 
(due to lack of motivation) leads to drug-taking and recently, for the first
 time, serious crime. [He] was arrested two months ago on a charge of armed 
robbery ($150 from a shop). At the time he was under the influence of drugs 
and alcohol. The offence was typically bizarre in that he gave us pre-advice
 and we were able to alert the police beforehand. But they could not prevent
 the happening — in which there was no bodily harm. If [he] did not suffer 
from a depressive illness we feel sure this would not have happened.39 
• One Cambodian woman who suffered from — well, she'd suffered all the appalling 
experiences that anyone from the Killing Fields could have suffered...and 
finally found herself in Australia and suffered then a very, very major 
psychotic illness — depressive — and during the course of this illness 
believed that the giant who had raped her, a brutal man in the refugee 
camp from which she fell pregnant, was coming to kill her now. And the 
voices in her head were telling her she deserved to die and she was going 
to be killed by this person, and this person was now embodied in her infant.
 So she attempted to kill this child. Subsequently, she was arrested and 
taken to the women's prison...40 
• [An] example of someone with a fairly obvious psychiatric or psychological 
problem...but she's quite harmless: this particular woman self-medicates with 
cannabis, so therefore, she has been convicted on a number of occasions, and 
served short sentences; or if she's fined, it's impossible for her to pay a 
fine, and she ends up cutting out the fine in the watchhouse.41 

Human Rights and Equal Opportunity Commission Page 757 

Mentally ill people are especially likely to 'commit' certain offences such as 
drunkenness, offensive behaviour, disorderly conduct, loitering or vagrancy 
(which commonly coincides with homelessness).42 Or it may be simply that 
they are more likely to get caught.43 A Queensland witness described 'the case 
of an old man': 

At the age of 76 his memory was shot. He was arrested in Cooktown for indecent 
exposure: he piddled on a tree in the main street. He didn't turn up in court
 because, amongst other things, he can't remember what day it is. So he was 
sentenced to 14 days for failing to appear. 

He was transported, at great taxpayers' expense, from Cooktown to Cairns; 
put in the Cairns Watchhouse. When he'd served his 14 days out he was released; 
he didn't know where he was. He went across to the Esplanade just across 
from the police station, stood there for a while, had a drink of water, 
felt the call of nature, piddled on a tree again, as was his way when he 
lived in the bush — and straight back into the watchhouse.44 

Non-payment of fines is another common avenue to prison for mentally ill 
people who are poorly organised financially,45 or who do not comprehend that 
they owe money.46 

One witness to the Inquiry described many of these minor offences as 
'victimless' crimes: 

A sentence to prison for essentially non-criminal behaviour adds another 
unshakeable label to those already ascribed to a mentally unwell person, 
and the process of alienation is an even greater burden.47 

Mentally ill people may be at increased risk of being charged with offences 
they did not commit. Improbable confessions by people with psychiatric 
disabilities are fairly common. (One recent example concerned the death of a 
resident in a hostel for people with psychiatric disabilities. Six other 
residents reportedly confessed independently to having killed her.48) 

People who do not have full control over their lives can also suffer the legal 
consequences of others' carelessness or misdeeds. The Inquiry was told of a 
mentally ill man whose financial affairs were in the hands of the NSW 
Protective Commissioner: 

This man attempted to commit suicide by lying on the railway tracks. He was
 picked up by police who found that he had outstanding warrants, and he was 
brought to prison... He believed the warrants had been paid by the Protective 
Office. On checking, $250 had been paid by the Protective Office; there was 
$200 outstanding. But the court computer did not show any payments, [so] 
he served seven days in prison.49 

Page 758 Mental Illness Inquiry 

Once arrested, mentally ill people may have trouble getting release on bail — 
because they are too poor to raise bail, because they have no fixed address, or 
because they do not comprehend or comply with bureaucratic requirements. For 
example, the Inquiry heard evidence about an offender whose bail was 
approved, but who refused (due to delusional beliefs) to sign any forms. The 
authorities felt they had no choice but to retain this individual in jail.50 

Failing to obtain bail means people affected by mental illness are frequently 
remanded in custody — even on quite trivial charges. The same problem arises 
when they are tried, convicted and due to be sentenced. The policy of most 
court systems is to favour non-custodial sentences such as fines, bonds, home 
detention and community service orders. But these cannot be imposed on 
someone who has no money and no secure accommodation. Thus people with 
a mental illness, for whom prison is a particularly inappropriate and harmful 
penalty, often go to jail for minor offences which normally would attract a 
noncustodial sentence.51 

Similarly, when an offender is due for parole or remission, the absence of 
secure accommodation can be reason for being kept in prison.52 A NSW 
psychiatrist recounted the case of a prisoner with mental illness and an alcohol 
problem, who was found not guilty of an offence on the grounds of mental 
illness: 

He has now made serious attempts to deal with the alcohol problem by having 
counselling and going to AA meetings in prison, has spent about four years 
in prison and could be released, providing there is ongoing supervision... 
But because of difficulties in arranging future management, the man in fact 
remains in prison.53 

Mentally ill prisoners' inability to cope with the distressing living conditions 
may also make them more likely to commit disciplinary offences in jail. One 
example recounted to the Inquiry concerned a man who, due to mental illness, 
had moved in and out of jail and psychiatric wards all his life. At the time of 
the Inquiry he was in Alice Springs Prison, having committed several offences 
after his local mental health service lost its psychiatrist and discontinued his 
treatment. While in jail (still receiving no treatment) he was charged with 
assaulting prison officers: 

He had been locked in his cell without access to water on the hottest day of the
 summer. When he was refused water, he became angry and caused damage to the cell. 
Two prison officers entered the cell to prevent further damage and it was alleged
 that [the prisoner], a man of 61, headbutted one of the officers... A further 
assault was alleged [later on].54 

These assaults and similar incidents were used as a reason to deny the prisoner 
day leave or parole, which he applied for in order to undertake a rehabilitation 

Human Rights and Equal Opportunity Commission Page 759 



program arranged for him by the Disability Service of Central Australia.55 Yet 
he obviously needs rehabilitation to help him 'unlearn' the institutional 
behaviour (including outbursts of aggression) which he has learned over years 
in prison.56 

Evidence presented to the Inquiry also established that some people unnecessarily 
enter or remain in jail due to poor quality legal representation, or poor 
communication with their lawyers: 

They have difficulty communicating with their legal representatives, particularly 
if they're Aboriginal; if their English isn't good; if their behaviour is bizarre;
 if they are aggressive, as people with some mental illnesses frequently are...57 

Some lawyers may feel uncomfortable with a mentally ill client: 

I first came across a solicitor, actually, in the courtroom when they were doing 
whatever it is they do. He refused to address me by name or to introduce himself,
 so I just made the statement that I refused to accept his assistance.58 

Solicitors are prone to say when they have someone who has either an intellectual 
impairment or a psychological problem, that they find it impossible to take lucid
 instructions from them. But I think most people who are prepared to spend a little
 bit of time would be able to communicate with these people...59 

Prison as an Avenue to Treatment 

There certainly are times when people who are known to be 'mad' are actually treated
 as 'bad', because it flows from that that at least they will get some psychiatric 
treatment.60 

Paradoxically, some evidence to the Inquiry pointed to the use by the courts of 
prison sentences as a means of providing access to accommodation and 
treatment. For example, one Victorian submission referred to a report of a 
judge remarking that if a particular offender were released on a bond, he would 
have to wait at least 18 months for suitable accommodation and treatment; but 
in jail he would go to the top of the waiting list for a secure psychiatric unit 
within the prison system, where he would receive treatment at once. The judge 
described this state of affairs as 'totally obnoxious and deplorable.'61 The 
Inquiry agrees. 

Does Jail Lead to Mental Illness? 

We know, and the doctors know, that he will be unable to cope with jail and the
 result will be an even more traumatised human being with even less chance of 
future wellbeing.62 

Page 760 Mental Illness Inquiry 

Contact with the criminal justice system is stressful for anyone. For a person 
with a mental illness the criminal process (being apprehended by police, 
arrested, bundled into a paddywagon, charged, tried and incarcerated) can be 
especially confusing and distressing. It can also be dangerous — because 
conditions in jail are likely to exacerbate mental illness. Mental health care 
is generally poor and at times non-existent. Living conditions in some detention 
facilities are disgusting. In addition, the procedures of our criminal justice 
and penal systems sometimes discourage people who are mentally ill from seeking 
treatment, by punishing them with longer sentences and even worse living 
conditions than usual. 

Prison Living Conditions 

The environment we place them in is intellectually, socially, occupationally
 sterile, and it doesn't help their condition at all.63 

The ordinary living conditions in prison are stressful and dehumanising — 
precisely the opposite of the therapeutic environment required by people with 
mental illness. Even for people who are not already mentally ill, the conditions 
are very conducive to depression: 

Imagine a place without a tree; a high-walled place where sunsets and sunrises
 cannot be experienced; a place without a dog or other pet; a place without a 
child, or often a person of the other sex, without elderly people; a place where 
one is almost totally without an opportunity to make choices, where one is cut off
 from family and friends to the extent that partaking in a relative's funeral,
 or a visit to the hospital of a seriously ill one, is a privilege; a place 
where very few people have meaningful (or any) work; a place where you have no 
choice of companions — and you have some idea of the vast majority of, if not
 almost all, prisons.64 

Conditions in Australian prisons, detention centres and police lock-ups have 
been condemned by numerous Royal Commissions, inquiries, reviews and even 
by Amnesty International.65 

Witnesses to the Inquiry cited many aspects of prison conditions which are 
particularly detrimental for those with mental illness. NSW came in for 
especially severe condemnation; based on the evidence received, our 'Premier' 
State could claim the dubious distinction of having Australia's worst prison 
conditions.66 One major problem is overcrowding.67 In mid-1991 NSW had 
over 7000 people in prison68 — nearly half of Australia's total, and three 
times as many as in the next most populous state, Victoria. Over the decade 
since 1981 the average prison population in NSW increased by 60 percent — 
compared with about 30 percent for other jurisdictions. (In Tasmania it actually 
declined.)69 

Human Rights and Equal Opportunity Commission Page 761 

Witnesses considered this overcrowding has been aggravated by the changes in 
prison policy introduced by the Coalition Government in NSW™ — and that 
these changes have created a climate of increased hardship which damages the 
emotional wellbeing of all prisoners.71 Simultaneously with the rapid increase 
in prison numbers came a cut in staffing levels: 

And then because of the staffing cuts, the number of hours that the individuals
 are locked up in their cells was increased. So that they're now in maximum 
security locked into their cells at 3.30 in the afternoon and released again at
 about 8 o'clock in the morning.72 

Personal possessions policy (NSW) 

Some crims have no family and are here for a long time. All they have are the
 things in their cells.73 

Perhaps the most infamous policy change in NSW was the crackdown on 
personal possessions. Prisoners were told they had three days to dispose of all 
their possessions, including their clothes, books, letters, watches and address 
books; any property remaining in the cells would be confiscated and sold. Some 
prisoners were able to get relatives to take their possessions, but others could 
not organise this in three days — especially those incarcerated long distances 
from their families.74 

The confiscation of wedding rings received wide media attention,75 but the 
loss of other possessions was equally disturbing and demoralising: 

They're allowed one certain size photograph. So for [prisoners] who have a number
 of children, if they had a number of different photographs of their children, 
then these were taken... Some of them became very upset and behaved very badly 
when the photos of their children were taken away.76 

Radios, cassette players and tapes were also removed, including relaxation tapes 
used to reduce stress.77 One prisoner with schizophrenia, who listened constantly 
to a radio, 'became a behavioural problem and [began] to scream all 
the time' when the radio was taken away.78 Another behaviourally disturbed 
prisoner had a talent for drawing; 

[The authorities] took all drawings away, and so [this prisoner and others] 
were left with nothing to do, you know, so that they're just left for this 
long period of time being bored.79 

Prisoners were no longer allowed to wear their own clothing. This was not a 
unique rule among Australian prison systems, but the NSW policy appeared 
particularly restrictive: 

Page 762 Mental Illness Inquiry 

I think for the women it's...two sets of underwear, one t-shirt, one pair
 of tracksuit pants and one dress — prison dress.80 

One survey reported a large number of complaints by prisoners about the 
clothes they were obliged to wear: 

In February 1991, during extreme heat, inmates at Parramatta Gaol were still
 wearing winter tracksuits because no summer clothing was available... Not
 all sizes of underwear are available (particularly the more common sizes).
 Prisoners complained that often the only size available was size 24... 
Generally there is a shortage of prison issue clothing. One prisoner 
complained that he 'couldn't change clothes for a week' when first put in remand.81 

The same survey revealed that the removal of tables from prison cells had 
created a practice as degrading as it is unhygienic: 

One inmate of Maitland Gaol wrote... 'as a result of this new measure, [we] have
 to eat our food on the floor or toilet seat, which of course goes beyond the 
bounds of humanity or human rights.'82 

Other aspects of the personal possessions policy also compromised prisoners' 
physical health: 

Among items confiscated were prisoners' hats, thongs and sunglasses. As a result,
 many prisoners working outside in the hot summer sun had no protection from the 
sun's rays. Ironically, this occurred as the Department of Health launched a h
igh-profile campaign ('Me-No-Fry')...urging 'common sense' preventive measures 
(such as wearing hats and using sunscreens)... In a similar vein, the prohibition
 on prisoners owning thongs has directly increased their chances of contracting
tinea in communal showers.83 

The prohibition on hats was subsequently relaxed, and prisoners could apply for 
thongs on medical grounds — but only after they contracted tinea.84 

Another policy change was a drastic reduction in educational facilities, which 
particularly disadvantaged prisoners who had had difficulty in their pre-prison 
education.85 

Conditions in the NSW jails also affect prisoners from the ACT, who are sent 
there to serve their sentences because the ACT has only a remand centre. This 
arrangement is a cause for concern in the Territory: 

There is no guarantee that these prisoners will receive treatment for their 
illness or even be housed in safety. There is no supervision by ACT authorities 
of prisoners in this system.86 

Human Rights and Equal Opportunity Commission Page 763 

On the eve of this Report going to print (August 1993) the NSW Minister for 
Justice announced the official abandonment of the harsh personal possessions 
policy.87 The Inquiry considers this decision to be long overdue. 

Other aspects of prison conditions 

Although NSW jails were the most frequently criticised, evidence to the Inquiry 
also indicated routine abuse and neglect of human rights in other states. A 
Western Australian witness pointed to the very harsh punishment meted out to 
escapees: 

They can receive up to three years' extra time, plus withdrawal of all privileges,
eg no radio, TV, library, no contact visits, plus solitary or near solitary 
confinement for six months. The first time the harsh escape punishment was applied,
 one of the two men committed suicide after two weeks. He left behind a two-year-old 
child, a wife and two stepchildren. You can imagine the mental health stress on that
 family, and the family of the second man... If such harsh treatment were for 
deterrence, then it failed, for three men attempted to escape, two successfully,
 from the same prison not many months later.88 

Prisoners generally have little or no choice about the geographic location where 
they serve their sentences; and forensic psychiatry services are only available 
in certain jails. This can result in even more isolation from family and friends. 
In Queensland: 

One of the difficulties with forensic services is it's all centralised... For those 
patients who have family members and who come from outside the general Brisbane 
metropolitan area, it involves long distance travel in order to maintain social networks.89 

One practice which causes significant distress is the abrupt forced relocation of 
inmates to different prisons.90 A forensic psychiatrist told the Inquiry: 

Inmates are moved very quickly from prison to prison and sometimes are cut off...and
 I think that the stresses involved are unreasonably punitive... For example one of 
the prisons which I currently visit is the prison at Lithgow... There's quite a distance
 between the town and the jail; travel arrangements are not easy, and in the first three 
or four visits that I made to that place I had a constant series of prisoners coming and,
 with very good reason, explaining why having been transferred to that prison at short
 notice made it almost impossible for them to either organise their defence properly 
or to keep in contact with wives or loved ones or to see their children.91 

The witness pointed out that this makes a mockery of the right Australia has 
committed itself to under Standard Minimum Rule 37: 

Prisoners shall be allowed under necessary supervision to communicate with their 
family and reputable friends at regular intervals, both by correspondence and by 
receiving visits.92 

Page 764 Mental Illness Inquiry 

A common complaint from transferred prisoners is that their few personal 
possessions are not transferred with them, but are lost, damaged or delayed en 
route.93 The same applies to their records — including health records. In the 
case of one severely mentally ill prisoner with a history of violence, who was 
transferred from Long Bay to Lithgow: 

Three weeks after he was transferred there, the psychologist at Lithgow was unaware
 of his existence.94 

Prison psychiatrists are sometimes not consulted about transfers of prisoners 
whom they are treating: 

I think the communication certainly should be improved about things like the movement
 of prisoners that we're [treating]. If we were consulted sometimes, we might be able 
to prevent problems by suggesting the prisoner not be moved, or should be moved...95 

Victoria's Police Surgeon gave evidence of a practice colloquially known as 
'cell circuit shuffle', whereby prisoners believed to be mentally ill are moved 
to a different watchhouse every few days. He said this severely dislocates any 
continuity in assessment and medical care.96 

The abusive social environment in prison is itself dangerous for inmates 
affected by mental illness. In a setting where any vulnerability is liable to be 
exploited, they may be easily victimised by other prisoners. The Inquiry 
received evidence of harassment, harsh punishment and violence,97 which in 
at least one case apparently precipitated the suicide of the mentally ill 
prisoner.98 

Alice Springs Prison 

The dormitory [we] visited occupied a whole building... The interior was entirely open
 plan but was subdivided by wire mesh into seven or eight discrete sections, in each of
 which were six or seven beds (bunks and singles), an unscreened urinal and a cold water
 tap. There were no facilities, nor indeed any space, for prisoners to keep personal
 belongings... It was hot and despite the open eaves, smelled strongly of sweat and 
urine... Prisoners are confined to the dormitories for 16 hours a day...[and] obliged 
to use toilet facilities within their caged subdivisions with little or no privacy.99 

This visit led Amnesty International to single out the Alice Springs Prison as 
probably breaching international human right standards on 'cruel, inhuman or 
degrading treatment'.100 (These conditions also constitute a breach of ICCPR 
Article 10, requiring that people 'be treated with humanity and respect for the 
inherent dignity of the human person'.) 

Human Rights and Equal Opportunity Commission Page 765 

One submission to the Inquiry concerned conditions at Alice Springs Prison and 
an inmate who had been affected by mental illness all his life. He was initially 
detained in 'isolation' — at his own request, because he feared harassment from 
other prisoners. However, his isolation lasted four years, in conditions which 
clearly violated Australia's human rights treaty obligations. 

He was not allowed to speak or otherwise communicate with other prisoners and they were not
 allowed to approach him. The cell is [2m] by [3m] and consists of a fully enclosed room with
 one high barred window. Outside the cell is a small yard...about twice the size of the cell,
 and [he] was allowed about half an hour exercise in the yard per day. 

During the winter [he] was often subjected to his cell and his person being hosed down
 at night. In winter the overnight temperatures in Alice Springs often drop below zero.101 

Conditions in Police Custody 

While most complaints about conditions of incarceration related to prisons, the 
Inquiry also received evidence about police cells and watchhouses, where many 
prisoners are held while awaiting trial, bail or transport to jail. The police 
surgeon in Victoria observed: 

[As for] psychiatrically disturbed prisoners in police custody...the majority of such
 prisoners are housed in appalling conditions. The state's largest holding facility, 
the City Watch House, bears a striking resemblance to its neighbouring structure, the
 Old Melbourne Gaol, which thousands of tourists visit to view the horrific conditions 
prisoners experienced a century ago.102 

In early 1993 the Legal Aid Commission of Victoria expressed concern that the 
holding cells in the State's newly built court complexes breach the UN Standard 
Minimum Rules for the Treatment of Prisoners: 

Unfortunately the Victorian Police Department's viewpoint in the past has been that the 
UN standards are guidelines only and there is no requirement to comply.103 

The Commission's specific concerns were with the design of the cells, which 
breach the Rules requiring access to fresh air, decent toilet facilities and open air exercise.
 However, it also cited individual cases of abuse and neglect. For example, one offender was 
sentenced to a lengthy prison term and should have 
been taken immediately to jail. Instead: 

[He] was held in the cells for ten days after his hearing. He had not had a change of clothes
 in that time, nor had he seen daylight.104 

For a person with a mental illness, such a delay can be especially damaging: 

Page 766 Mental Illness Inquiry 

A defendant with psychiatric problems was held in custody pending a bail application, with a 
direction that a forensic psychiatric report be prepared. The Office of Corrections refused 
to send a psychiatrist, and the defendant was not transferred to the Remand Centre or other 
facilities where psychiatric services could be available. The defendant was held in local 
cells for three weeks before being brought to court, again for a bail application — without
 the report.105 Other issues raised by the Commission include overcrowding, the total denial 
of visits at some police cells, and health problems including food poisoning, skin rashes and
 colds. In addition, the conditions in which solicitors are expected to speak to their clients
 are primitive. 

A solicitor interviewing a prisoner must stand behind a white line some ten feet away. There
 is no desk, bench or seat. The interviewer stands in the open air and is exposed to all weather.106 

Instructions from prisoners are taken through a grill door... Instructions can be overheard 
by both police and other prisoners.107 

The Royal Commission into Aboriginal Deaths in Custody identified chronically 
bad cell conditions as one factor contributing to the high rate of deaths in police custody. 
Since the Royal Commission, governments have exerted pressure on 
police to improve conditions and procedures. Conditions have improved, 
particularly in some areas of Queensland and the Northern Territory.108 New 
police stations are now built to better designs — but many are still inadequate, 
considering the extended periods some prisoners spend in police cells (see 
below). For example, the new police stations at Innisfail (Queensland) and 
Katherine (NT) have spacious cells designed for multiple occupancy: 

They are well lit and ventilated and protected from the hot sun. Both employ closed
 circuit television, are fitted with cell alarms, are manned for 24 hours, are clean
 and well decorated, and are fitted with lavoratories, drinking fountains and showers.
 However, neither provides any natural light, nor has any outside exercise facilities, 
nor offers even a semblance of privacy... It is doubtful whether prolonged custody in 
such cells could be described as humane.109 

The Inquiry also heard disturbing accounts of the conditions in which people 
known to be mentally ill are transported to jail or to hospital by police: 

I was taken from Townsville to Brisbane in the back of a police paddywagon, psychotic 
and very distressed. When the police would have a meal break or something, they'd just 
throw me into one of the local cells, wherever they happened to be... One of those was
 a padded cell with no toilet facilities, no furniture, and bloodstains all over the cladding.110 

(This issue is addressed in more detail in Chapter 8.) 

Human Rights and Equal Opportunity Commission Page 767 

Assessment for Mental Illness in Prison 

The medical services...shall include a psychiatric service for the diagnosis and, 
in proper cases, the treatment of states of mental abnormality.111 

Before an illness can be treated it must be recognised. However, a great deal 
of mental illness goes undiagnosed in prison. This is due, in part, to inadequate 
assessment on initial admission to prison. 

A South Australian witness referred to 'a lack of formal process as to how 
people with mental illness are identified as they enter the correctional services system.' 
Even when psychiatric reports are presented during a trial or at sentencing, those 
reports are not necessarily passed on to prison or probation officers.112 

In NSW the prison regulations provide that the prison medical officer should 
'cause each prisoner to be examined as soon after reception as is practicable'; 
and then 'to cause to be carried out such medical examinations, investigations 
and treatment of such prisoners as may be reasonably necessary.'113 However, 
a review of the NSW Prison Medical Service found that in practice, 

nursing staff generally have total responsibility for the assessment process. Medical 
staff are only called on where necessary, generally through referral to Doctor's 'sick 
parade' when next available. The assessment process is generally short, and revolves 
around the completion of a reception form...which collects only limited information.114 

Evidence presented to the Inquiry suggests an even less thorough process is the 
norm. One expert witness gave evidence that most prisoners undergo a blood 
test for HIV on reception; but apart from that, there is no routine medical or 
psychological assessment: 

This is not done, because there is no funding. All agree it should be done.115 

Despite this lack of systematic assessment, a psychiatrist who works as a 
consultant to the NSW Corrective Services Department claimed that 'the great 
majority of prisoners with psychiatric disorders do come to the attention of the 
Prison Medical Service, and do receive at least some psychiatric attention while 
in jail.'116 

By contrast with NSW, Victoria has a systematic reception process which is the 
joint responsibility of the correctional and health authorities. A doctor examines
 and assesses all new prisoners; certain categories are typically referred on to other
 professionals such as a psychiatric nurse, psychiatrist or Aboriginal welfare worker. 
These categories include young prisoners, sex offenders, first-

Page 768 Mental Illness Inquiry 

timers, prisoners who are despondent, distressed, overly anxious or psychiatrically 
disturbed, those withdrawing from drugs or alcohol and Aboriginal and Torres Strait
 Islander people.117 

A witness from a prisoner support group said this assessment process 'has been 
a great asset...a great improvement'.118 Even so, it is far from 100 percent 
effective: 

Not all people who have either mental illness or severe behavioural disorders are 
in fact identified through the process...and even [among] those who are identified,
 those who don't appear at the time to require immediate treatment often move through
 into the mainstream of the prison environment, and often the...illness can 
[become worse] at a later stage.119 

This witness particularly lamented the fact that the reception process applies 
only in adult jails, and not in juvenile correctional facilities.120 NSW witnesses 
also raised the absence of assessment for juvenile offenders in custody. This 
omission means mentally ill juveniles are denied the treatment they need; but 
also has more far-reaching implications: 

It also means that those young people who have mental health problems specifically
 arising as a result of their custody tend to go untreated. And obviously, for...
custody centres it creates all sorts of management problems, and that results in 
more young people being transferred to adult facilities.121 

A more detailed discussion of issues affecting mentally ill juveniles in detention
 is contained in Chapter 20. 

Assessment on Entry into Police Custody 

Well before alleged offenders reach jail, they become prisoners of the police. 
Over 25,000 people are taken into police custody in an average month.122 The 
police themselves recognise that being arrested and locked up can be a 
traumatic experience: 

Several factors combine to traumatise a prisoner, eg the indignity and shame of arrest,
 guilt about the offence, concern about imagined police harassment, the physically
 depressing nature of many cell areas, isolation and confinement in a cell, fear of 
the legal process, worry about the social and employment consequences, etc.123 

Over one-third of suicides in custody (and nearly 40 percent of custodial deaths) 
occur in police custody.124 Clearly the period immediately after arrest is a critical
 time for assessing the mental health of prisoners. Anyone taken into custody 
who appears to require mental health treatment should be taken 
immediately to a hospital. 

Human Rights and Equal Opportunity Commission Page 769 

Victoria requires anyone in police custody to be assessed if they appear to be 
psychiatrically disturbed. Police officers themselves decide whether a particular
 individual requires assessment; to this end all police receive specific training 
in mental illness.125 The assessment itself is conducted by one of 45 medical 
practitioners who are on call for this purpose throughout the State:126 

Frequently the assessments are performed in less than adequate surrounds: rooftops,
 prison cells, the rear of divisional vans and backyards, intermingled with screaming 
and yelling, blue uniforms and weaponry, distraught family members and angry 
neighbours... The luxury of fixed appointment times, subdued lighting, soothing 
music, designer colour schemes and couch are never available.127 

In principle, NSW police have a screening procedure too. It is based on the 
Prisoner Admission Form, a questionnaire which officers are required to follow 
with every person detained. However, a recent inquiry by the State Ombudsman 
found that the procedure is sometimes regarded as merely a routine task 
preceding incarceration. Sometimes it is performed inadequately; sometimes not 
at all.128 

In North Queensland the police apparently lack even the most rudimentary 
screening procedure. One witness, representing a prisoner support group, said 
'the Cairns watchhouse.is notorious.'129 She cited the example of one 
prisoner, 

who was, amongst other things, on medication for epilepsy. He wasn't getting it.
 We had quite some difficulty...to arrange that he did get taken to hospital to 
get it. [By then] he had been fitting over a number of days.130 

The importance of assessment 

The Royal Commission into Aboriginal Deaths in Custody stressed the 
importance of identifying prisoners at risk of suicide. It recommended that all 
police and prison officers receive basic training in recognising warning signs, 
and 'Suspicion that all is not well must result in urgent medical referral.'131 

Similarly, the NSW Ombudsman has observed: 

One of the major factors in suicide prevention is an effective screening process.
 The basic elements of the process are well recognised — the practical implementation
 of them does not appear to have received sufficient attention.132 

It appears that Victoria's screening process has been effective. When the 
procedure was first implemented, Victoria was averaging six or seven prison 
suicides each year, with 11 in the previous 18 months. By early 1991, after 

Page 770 Mental Illness Inquiry 


more than two years of the screening procedure being used, there had been no 
further suicides.133 

Treatment of Mental Illness in Custody 

Our management of psychotic prisoners is made extremely difficult by lack of time,
 lack of proper facilities, and the fact that almost inevitably a psychotic prisoner
 has to go into segregation. And...segregation means an awful lot of time in a cell,
 very little exercise, and at times conditions close to sensory deprivation — 
which almost inevitably predicts a worsening of the psychotic condition.134 

A recurring irony throughout evidence presented to the Inquiry was that the 
people who are most needy and most vulnerable in our society are precisely the 
ones who are denied the treatment they need. The evidence about prisons was 
no exception. Most prison medical services include some form of mental health 
care dispensed by doctors, nurses, psychologists or social workers. However, 
these services are seriously deficient — in terms of both resources and 
coordination with prison authorities. As a result, the treatment offered to 
prisoners affected by mental illness is usually inadequate, often inappropriate 
and sometimes downright brutal. 

The Inquiry was told 'the care of people with schizophrenia in Queensland jails 
is practically non-existent.'135 In prison systems which do provide 'treatment' 
for severe mental illness, one of the most frequently used 'tools' is isolation: 

The traditional method of [treating] someone who's showing bizarre behaviour 
is to strip them naked and leave them in a cell, sometimes for 24 or 48 hours —
 but sometimes that isolation goes on for days and even weeks.136 

At Mulawa Women's Prison in Sydney, the Inquiry was told, prisoners believed 
to have suicidal tendencies are put in a 'dry cell', which contains nothing 
except a bucket toilet and a gym mat on the floor. In 1991 there were two of 
these cells: 

One of them is in a very old building which is very dilapidated, and actually has
 a toilet basin which is not connected to the plumbing so it's not useable... 
The other dry cell, which was built only a few years [ago]...has no ventilation at
all, no windows, except for a small slot very, very high: I think the intention here 
was to provide something which was said to be suicide-proof. And a very heavy iron door
 — it faces east, and...I was called down there on a very hot day this summer, 
when the temperature must have been about 30' outside, and it must have been 50' 
inside the cell. It was just dreadful, and the smell of urine from the bucket 
and the cramped, dark conditions are just horrible. I think it's terrible to
 consider that it was built so recently — that anybody could have designed 
anything like that so recently.137 

Human Rights and Equal Opportunity Commission Page 771 

A South Australian witness said that when treatment is provided, it is 
overwhelmingly 'medical', with no rehabilitation. Even the limited program of 
activities available to ordinary prisoners may be inaccessible to those with a 
mental illness because, being especially vulnerable to violence, they are often 
housed in special protection units which restrict their movement.138 

The Inquiry heard disturbing allegations of the use of psychiatric medication as 
a management tool in prisons. For example, in Western Australia: 

Although we have no accurate statistics...one comment to come to us regarding 
Fremantle Prison was that 70 percent of inmates were on prescribed medication.
 From practical experience, we have noted an alarming number of women whom we have 
interviewed at Western Australia's women's prison, Bandyup, being under the 
influence of presumably prescribed drugs.139 

We are concerned that these people [who are not really mentally ill] are given
 medication whilst they are in prison, and people who actually do have some mental
 illness which should be treated are also given medication, so it is hard to 
distinguish one from the other. Everybody is just seen as taking some sort of 
medication to keep them quiet.140 

The use of medication as a management tool is an abuse of the human rights 
of all prisoners, mentally ill or not. It also inspires little confidence that 
those affected by mental illness will have their needs appropriately met. 

An allegation that trading in medication occurs was also made to the Inquiry: 

When a psychiatrist sees mentally ill people in jail and prescribes medication,
 I believe that the medication is not made up and given personally by the doctor,
 but the prescription is given to the prison warders. There is a strong inference 
that this medication then finds its way not to the patients, but is used for 
'trading' in sedatives.141 

Denial of Treatment in Prison 

My son was denied psychiatric assistance when all the circumstances screamed out
 that this was essential, and according to the Mental Health Act was his right, and was requested.142 

In most parts of Australia prisoners have no legal right to treatment for mental 
illness as prisoners; prison statutes require only that inmates be given access 
to such medical treatment as is considered necessary by the prison authorities.143 
Sometimes prisoners receive no treatment at all, even if they 
are known to have a mental illness before going to jail: 

In recent times...it was not uncommon at times for a person with very severe 
psychiatric illnesses being admitted to prison, perhaps on remand, automatically 
having their treatment stopped, because...those were the rules.144 

Page 772 Mental Illness Inquiry 

It is particularly abhorrent that people who are in jail largely (or entirely) 
because of their mental illness are denied treatment for it: 

You are actually preventing the inmate from seeking treatment... I saw people who
 had been in prison for eight years in such a way, and prevented from seeking 
treatment of any kind.145 

One report to the Inquiry concerned psychiatric medication being denied to 
prisoners as a form of punishment.146 

In most parts of Australia a prisoner who displays current, obvious and extreme 
psychotic symptoms will eventually attract some form of medical attention. 
However, 'lesser' conditions, including depression, neuroses or personality 
disorders, are often not seen as meriting intervention: 

Where people are defined as being not psychotic, it is [assumed] that they don't 
necessarily require the same expertise or delivery of service, in terms of quantum 
or services available.147 

Unfortunately, these other conditions can be extremely serious and sometimes 
even fatal. 

Denial of Treatment in Police Custody 

If treatment for mental illness is difficult to obtain in prison, it is virtually 
impossible in police custody. Every prison system provides at least a rudimentary 
health service which has no counterpart in the police lock-ups. 

In theory there should be little need for mental health care in police cells. 
They are designed for very short stays. The prisoners are people who have been 
denied police bail and are only being held until they can be brought before a 
magistrate — the next day, or at most over the weekend. Generally speaking, 
this is true: half the people taken into police custody are held less than five 
hours, and 87 percent less than 24 hours.148 

However, in reality, police cells are frequently used as back-up accommodation 
for the prisons. 

Police cells were employed whenever prison accommodation was full; or pending 
(in remote locations) intermittent escorts to prisons; or by arrangement with
 the prison authorities because it was judged more economical or humane to let
 prisoners remain in police accommodation near their own community... In the 
northern outback of Western Australia, for instance, it is normal for remand 
or short-sentence prisoners...to remain in small police lock-ups.149 

Human Rights and Equal Opportunity Commission Page 773 

The Inquiry heard evidence of mentally ill people being held in Queensland 
watchhouses for two weeks,150 and of a young man held for three weeks at 
a suburban Melbourne police station.151 Melbourne's 'cell circuit shuffle', in 
which prisoners are moved between watchhouses every few days, has already 
been mentioned. Holding prisoners for such long periods must entail a 
responsibility on custodial authorities to provide (or at least allow) treatment
 for mental illness. Yet this concept is apparently unknown at some police stations. 

For example, people who know they are mentally ill and need medication may 
be denied it: 

Because they don't have training, [Queensland] police don't realise the 
importance of people continuing to take anti-psychotic medication. And because
their behaviour doesn't immediately deteriorate, they don't realise that it will 
deteriorate over a period of days or weeks, and they will...suffer more and more.152 

The young man held by Melbourne police for three weeks was withdrawing 
from drugs, suffering acute depression and anxiety, and bore obvious marks of 
a suicide attempt. His mother told the Inquiry that he was not allowed to see 
family members or any other people significant to him — including those who 
were treating him for his drug problem. Both he and his mother asked that he 
be seen urgently by a mental health worker, but these requests were ignored or 
denied. 

After three weeks in the police cells he was taken to Pentridge Prison, where 
he was placed in a cell by himself: 

With a history of serious and recent suicide attempts, his pleas and cries for 
help were ignored. He died within 24 hours.153 

For his mother the nightmare continued after his suicide:154 

The handling of [the] situation was appalling and lacking in any sensitivity to 
[my son] or his family... For example, I was not even informed of [his] move to
 Pentridge, until the Community Police came to tell me that my son had died in 
'protective custody', and to go and claim his body. The Prahran police were the 
first to offer any sensitivity and a kind word. For hours afterwards, I was not
 able to locate my son's body; then [I was] told I didn't need to identify him,
 just to make arrangements to bury him.155 

Such abuses of basic rights are intolerable. In a modern democracy they are 
also inexcusable. 

Transfer to Hospital for Treatment 

Persons who are found to be insane shall not be detained in prisons and arrangements 
shall be made to remove them to mental hospitals as soon as possible.156 

Page 774 Mental Illness Inquiry 

All Australian prison systems have provision for individuals who are severely 
mentally ill to be transferred into a psychiatric hospital ward and treated as 
inpatients. Some jurisdictions have such a ward within the prison system: eg 
Long Bay Gaol in Sydney. In other systems, severely mentally ill inmates are 
transferred out of the prison sector and into a secure ward in an ordinary 
psychiatric hospital. South Australia has a special ward for prisoners, James 
Nash House, which is part of the public hospital system. The question of 
whether these inmates should be treated in the health sector or the prison sector
 is controversial (the arguments on both sides are addressed below). 

The Inquiry heard few complaints about the treatment which mentally ill 
prisoners receive once admitted to hospital. However, getting to hospital can 
be extremely difficult — virtually impossible in some cases, eg for women 
prisoners in NSW (see below). 

This issue was raised by a number of witnesses, including several from the 
ACT, which has no jail and therefore transports its offenders to serve their 
sentences in NSW. The Territory Government is concerned that prisoners 
affected by mental illness should have access to treatment. Yet prisoners from 
the ACT are forced to go without treatment at Goulburn Gaol, where there is 
no psychiatric service, while awaiting classification for the NSW prison system: 

There is no care, no control... We had a horrendous case two years ago of a young 
man who suicided after three days in Goulburn. He should not have ever been sent
 there. He was just too ill and too vulnerable — and that is always going to be
 a problem when we send people in a vulnerable condition to places like that.157 

The ACT authorities advised the Inquiry that they are trying to arrange for 
ACT prisoners who are mentally ill to go direct to the special facility at Long 
Bay in Sydney.158 

A blatantly discriminatory practice was brought to the Inquiry's attention in 
Tasmania: prisoners who become mentally ill in jail and are transferred to 
hospital do not have their time in hospital credited as part of their sentence: 

So a man sentenced to, say, one year's imprisonment, who falls sick within the first
 two months, is sent to a mental hospital, where he remains treated but incarcerated
 for a year before recovery — he has to return to prison to serve the rest of his 
sentence. So his sentence virtually becomes two years. In contrast, if he were 
physically ill, no such disadvantage would obtain.159 

This practice is apparently not confined to Tasmania. It was raised in evidence 
to the Inquiry in Queensland;160 and has also been highlighted by the Committee 
appointed to review the operation of the NSW Mental Health Act.161 

Human Rights and Equal Opportunity Commission Page 775 

Thus prisoners who are psychiatrically disabled are punished for their disability as 
though it were a further crime. Apart from being grossly unfair, this practice strongly
 discourages prisoners from seeking psychiatric assistance if they need it. This 
perpetuates the problem of mental illness going undiagnosed and untreated in prison. 

Special Needs Groups in Prison 

Women 

Recent changes have resulted in a decreased level of care so that the situation at
 Mulawa [Women's Prison] is the worst for many years.162 

Women comprise about 5 percent of the prison population,163 but the information 
available to the Inquiry suggests the prison system has largely failed to recognise
 their needs. 

Expert witnesses gave evidence that female prisoners affected by mental illness 
are often more disabled than their male counterparts. Female prisoners are 
reported to have more physical and mental illness generally,164 and an 
especially high rate of alcohol and/or drug problems.165 The diagnosis of 
'personality disorder' is more frequent among women.166 They generally have 
less education, inferior social skills and less family support than male 
prisoners.167 Being incarcerated also creates particular difficulty for women 
who have children:168 

Pregnant women have no opportunities to bond with their babies, and for those 
children the opportunities for visits are limited ... 169 

And they are not able to deal with problems that arise with their children. They
 may receive [bad] news about the children or other family members and can't deal 
with it from where they are.170 

As mentioned earlier, a recent Tasmanian study established that about one-third 
of female prisoners admitted over the last ten years had a psychiatric history;
171 but the absolute number with psychiatric disorders has steadily increased in
 that time.172 Some have chronic, severe mental illness, but the most common 
diagnoses are 'personality disorder' or drug abuse.173 

Prison conditions for women (NSW) 

In Sydney the Inquiry heard from a psychiatrist who works as a consultant to 
the NSW prison system that conditions generally for women prisoners are even 
worse than for men: for example, there are fewer activities, educational 

Page 776 Mental Illness Inquiry 

programs, employment or training opportunities and little prospect of 
transferring within the jail system.174 At Mulawa, the women's prison, 
overcrowding created by the Government's new policy is particularly acute.175 
In 1989 there were 150 inmates at Mulawa; by 1991 there were over 300. At 
the same time, 

The facilities for treatment of prisoners suffering from any kind of emotional
 or psychiatric disturbance have decreased, so that there are less facilities 
available now than there were when there were only 150. 176 

Treatment for women with mental illness 

The NSW prison system provides no inpatient psychiatric facilities — and in 
fact no proper medical facilities — for women. Female inmates suffering from 
mental illness are generally 'treated' within the prison mainstream.177 

The Mulawa treatment regime contains several serious deficiencies. One is the 
use of the segregation unit to isolate women who appear to have psychiatric or 
emotional difficulties, especially if they are deemed by prison officers to be 
potentially suicidal. The segregation unit was purpose built, at low cost, as a 
punishment and deterrence unit: 

The general atmosphere evokes a feeling of punishment and indignation which is not 
conducive to any form of psychiatric treatment. There are no facilities for 
examination/interview and assessment, or for observation of prisoners. There is no
 24-hour nursing cover. Medication and files are not stored in the unit. Inmates 
are locked in cells from 3.30pm to 8.30am.178 

This building also contains the new 'dry cell' described earlier in this chapter.
 As if the setting were not punishment enough, segregated prisoners may be subject
 to the humiliation of being stripped naked. This is 'said to be for their own 
protection', to prevent them hanging or strangling themselves with items of clothing: 

And on some occasions...they are stripped by male officers and left stripped, 
sometimes for long periods of time... under observation by male (or maybe male
 and female) officers. There's only this gym mat and no blankets or covers.179 

This kind of treatment is distressing for anyone, but especially for a person 
with a mental illness. Moreover, a large proportion of female prisoners have 
previously been victims of sexual harassment or abuse;180 this practice creates 
the potential for such abuse to be repeated by prison staff.181 Even on grounds 
of simple physical health it is objectionable: the cell which gets so hot on 
summer days can also be very cold at night, but a woman who has been 
stripped is obliged to sleep naked and uncovered on the gym mat.182 

Human Rights and Equal Opportunity Commission Page 777 

Incredibly, the decision to put a prisoner into a dry cell and strip her is made 
entirely by prison officers, without any assessment or advice by any health 
worker. The psychiatrist who described this practice to the Inquiry made a plea 
for some health expertise to be involved: 

I would recommend first of all that there should be assessment by someone from the 
health team, preferably by a psychiatrist, but certainly at least by a nurse who's 
got some psychiatric training... I'm not saying prison officers are wrong to be 
concerned, but they should get professional help quite early.183 

In any event, the witness said she does not believe it is ever necessary 'to strip 
anybody completely and then leave them naked'. As a practicality, she 
suggested the use of heavy calico gowns and special blankets which are hard 
to tear into strips.184 However, there is obviously great scope to reduce the 
danger of suicide merely by involving staff who have some expertise in mental 
health — and by eliminating 'treatment' practices which actually exacerbate 
mental illness. 

Transfer to hospital 

In extreme cases, women who become acutely ill can be transferred to hospital. 
However, this is no simple matter. Unlike male inmates, for whom a hospital 
exists within the prison system, women must be transferred out into the general 
mental health system. 

In principle, Cumberland Hospital makes five beds available for female 
prisoners. But these five beds may be already full; even if they are not, the 
bureaucratic delay in transferring an inmate out of jail can be up to 14 
weeks!185 For a person who is suicidal or suffering from an acute psychotic 
disturbance, this delay is tantamount to official medical negligence. (It is 
certainly a violation of a sick woman's basic right to appropriate treatment.) 
The process of transfer essentially consists of a form being completed by two 
doctors, one of whom is a psychiatrist. It is a procedure which should take, 
according to the witness, 'a few days at the longest'.186 

In practice, for the many prisoners who are on remand awaiting trial, a quicker 
way to get into hospital is simply to wait for the day of their court hearing to 
arrive. A forensic psychiatrist makes the application under the Mental Health 
Act; the magistrate has the power to act on the application and send the person 
directly from the court to a hospital, 'if he considers that mental illness may 
have been a factor in the commission of the offence, or that the person needs 
urgent treatment.' Even so, severely disturbed women can spend several weeks 
in prison — a totally unsuitable environment — waiting for their court cases to 
come up.187 For example: 

Page 778 Mental Illness Inquiry 

A 54-year-old woman suffering from early dementia was admitted to Mulawa. She had been 
charged with 'trespass'... She had harassed the owners of a house where she had previously 
lived, telling them it was her house. Police took her [first] to a mental hospital, who 
refused admission. She spent three weeks in prison before she was transferred to a mental 
hospital from the court.188 

While waiting for a transfer, these acutely ill women are kept in conditions 
likely to aggravate mental illness. The expert witness gave other examples — 
including that of a young woman who had a history of psychotic episodes. She 
was sentenced to three months in prison. At the time of her admission to 
Mulawa she was stable and not on medication. However, she soon became 
distressed and then developed psychotic symptoms: 

When she expressed her delusional beliefs to prison officers, she was told not to tell lies and was
 transferred to a 'dry' cell because of her disruptive behaviour. At first she settled, but when she 
went to the toilet and realised the toilet could not be flushed, there was no toilet paper and she 
could not wash her hands, she became increasingly psychotic and her agitation increased. She began 
screaming and was told that the longer her noise continued, the longer she would remain in this cell.189 

The psychiatrist was gravely concerned: 

A Schedule 3 certificate was written by myself and also the other attending psychiatrist, for her 
transfer to a mental hospital as a matter of urgency. Medication was administered and she was seen
 as often as possible by one of us — but this young woman remained in the 'dry' cell for most of her 
three months imprisonment, as the Health Department stated that no beds were available in a mental hospital facility.190 

Such treatment of sick people is not only a violation of human rights — it is a 
disgrace to a nation that considers itself civilised. 

Women in male prisons 

Up until 1990 female prisoners who were mentally ill could be transferred to 
the hospital at Long Bay, an otherwise all-male prison. The Inquiry was told 
the women received 'very inadequate' treatment, and encountered strong 
prejudice from staff: 'a feeling that there was something really quite aberrant 
about being a female prisoner.'191 Women were strip-searched by male staff 
at Long Bay,192 and many were refused admission: 

There was a tendency...for them not to be accepted but just sent back on the grounds that they were
 being 'manipulative'... They were simply [deemed] 'personality disordered' and 'manipulative' and 
should be sent back to Mulawa — and a very high number of them were sent back within half a day or a 
day or so, some of whom I consider were actually quite psychotic and who later ended up in mental hospitals.193 

Human Rights and Equal Opportunity.Commission Page 779 

Women prisoners are no longer transferred to Long Bay psychiatric unit; 
however, the current arrangement with Cumberland Hospital is also patently 
inadequate. The psychiatrist who gave this evidence noted recent suggestions 
that disturbed women should again be moved to Long Bay: 

I am open to any of these ideas as they certainly would offer better opportunities than the
 present lack of facilities at Mulawa. However, these women are placed in a position where they 
are the minority in a group of psychiatrically disturbed inmates and they are thus in a very 
different to a normal situation... Their experience of males is mostly adverse, and their
 transfer to a male institution is generally regarded as negative and sometimes perceived as a punishment.I94 

She maintains the women prisoners 'would be better off being treated within 
the female prison system, with programs devised for females.'195 

Aboriginal and Torres Strait Islander People 

We're the most imprisoned race of people in the world.196 

Aboriginal and Torres Strait Islander people are over-represented in prisons: 
they constitute 1.5 percent of Australia's population (and less than 1 percent of the adult
 population), but 14 percent of prisoners.197 They are especially overrepresented in Western 
Australia, South Australia and the Northern Territory.198 Furthermore, these statistics on 
prison populations do not cover police cells. In police lock-ups the proportion of Aboriginal
 people is even higher: nearly 29 percent of those taken into custody nationally — an over-
representation by 26 times.199 

In Sydney the Inquiry heard evidence from LINK-UP, the support agency for 
Aboriginal people removed from their families as children, that the overwhelming 
majority of Aboriginal people in jail have suffered the mental effects, either 
directly or indirectly, of this separation.200 Witnesses also referred to the 
dispossession of Aboriginal people as a cause of profound spiritual, emotional 
and mental harm.201 

One of the functions of forensic psychiatrists and psychologists is to provide 
assessments for the use of courts, legal services, probation and parole officers. These reports
 allow mental disturbance to be taken into account in preparing a case, and for making decisions 
about sentencing and parole. A psychologist who regularly performs this role in the Northern 
Territory told the Inquiry that Aboriginal offenders do not get the benefit of this service,
 because the 'experts' understand so little about Aboriginal mental health: 

Page 780 Mental Illness Inquiry 


We can do it for non-Aboriginal people, [but] we really, at this stage, cannot do it with any
 sound theoretical base for Aboriginal people. I guess it raises a social justice issue: they
 are not getting a thorough enough job done.202 

One specific characteristic which still appears not to be understood by our 
traditional penal and mental health systems is that incarceration itself creates 
severe mental disturbance for Aboriginal people. The consequences are 
sometimes fatal, as the Royal Commission into Aboriginal Deaths in Custody 
has revealed. Witnesses to the Inquiry repeatedly stressed the seriousness of this issue, which 
is a deeply ingrained cultural difference between Aboriginal and non-Aboriginal people. As the 
parents of one prisoner said: 

While he's in jail over there...you know, he's not — just not like an Aboriginal over there. It's
 not [right] for an Aboriginal to be in that sort of situation all the time — locked up — because,
 you know, it's against our culture.203 

Whether the incarceration is in a prison or a psychiatric ward, the problem is 
the same. A solicitor in Darwin told the Inquiry the story of one of his clients, an Aboriginal
 man from a remote community who has schizophrenia.204 
Arrested in 1986 for a series of offences, he was sentenced in 1987 to detention 
under the Mental Health Act for up to six months. Taken to Alice Springs 
Hospital, he became violent, insisting he wanted to leave. He was then 
medicated and transferred to the security ward at Royal Darwin Hospital. He 
remained there, '1500km away from his family, his community, his language, 
his culture, his land', for over five years. When the Inquiry sat in the Northern Territory 
(and visited him) he was about to be transferred back to Alice Springs Hospital, closer to 
his community — but was still no closer to release. 

Why was this man's six-month sentence extended for so long? His solicitor 
explained what the hospital records reveal: 

All that [he] has ever wanted throughout the last seven years of custody up here is to be
 allowed to return to the Centre... Again and again, all the entries made...as to [his] 
conduct and his utterance throughout the day repeat this: 'When am I going home? When can 
I get back to Alice Springs?' 

The other thing that is quite clear...is the man's frustration... On several occasions 
during this seven years he was told by staff, 'Another six weeks in Darwin with a view to 
moving you down.' The next day's notes: '[Patient] very happy'; and the concepts they used
 disturb me, but these are the concepts they used: 'No management difficulties. Behaviour 
excellent. Not upset. Very happy. Excited about, looking forward to going down.' This would 
happen continuously over that period of seven years and then something would happen — an incident
 would occur... It did not happen. The Health Department would say, 'We didn't have the
 resources down at [Alice Springs]... He is dangerous. He fulfils 
the criteria.' 

Human Rights and Equal Opportunity Commission Page 781 


[He] would misbehave. Entries in the notes describing his misbehaviour follow thus: 
'[He] refuses to do the dishes.' [He] would always refuse to do the dishes! It is against
 his culture — he is an Aboriginal man from a settlement in Central Australia. There is
 no accommodation for that, it would appear, in the treatment of the man by the staff.205 

One Aboriginal witness warned against the assumption that disturbed Aboriginal 
people in prisons should be transferred to the mental health system, saying this 
'doesn't actually treat the cause, it just transfers one problem to another.'206 

People of Non English-Speaking Background 

A particular difficulty for prisoners from non English-speaking background who 
are affected by mental illness is the lack of interpreter services.207 The 
problem is not only insufficient services: 

We've had one instance of a prison warder refusing to allow an interpreter to go into the prison,
 because the warden felt all conversations should be in English — because they weren't sure what
 was actually being discussed.208 

Resistance may also come from the interpreters themselves: 

There have been a lot of interpreters who have not particularly wanted to go [out] to the 
prison, but...have been willing to meet elsewhere, at the courthouse in town, down in the
 cells there.209 

Other Groups 

Children and young people in custody who have a mental illness are another 
special needs group. They are discussed in Chapter 20 of this report. Two other 
groups of prisoners also at particular risk are older men with dementia or 
severe depression, and prisoners with developmental disability and behavioural 
problems.210 (See Chapter 21 — People with Dual and Multiple Disabilities.) 

Shortage of Staff and Resources 

It may be that one of the roles of a Commission such as this is to point out to governments 
that they really shouldn't go on doing things like this — establishing prisons, which of
 course we must have in our communities, but not staffing them properly.211 

The main reason why mental health care in jails is so poor is the shortage of 
staff.212 The Standard Minimum Rules require 'a sufficient number of specialists such as 
psychiatrists, psychologists [and] social workers'.213 Yet every forensic psychiatrist who 
addressed the Inquiry referred to the severe understaffing of mental health services for 
prisoners — a group with a very 

Page 782 Mental Illness Inquiry 

high rate of mental illness and other disabilities, living in an inherently stressful environment,
 and prevented from seeking assistance privately. 

The Prison Medical Service is the worst staffed area in the health (hospital or community) 
system in NSW.214 

The NSW Prison Medical Service (PMS), responsible for the health of nearly 
half of Australia's prisoners, relies mainly on part-time consultant psychiatrists. In 
October 1990 the amount of psychiatric time available was 100 hours a week — equivalent 
to less than three full-time psychiatrists! PMS psychiatrists are also required to provide 
court and tribunal reports and to attend some court hearings. When these activities are taken 
into account there is even less time available for providing psychiatric care to patients.215
 Given the number of prisoners requiring care, the number of psychiatrists available is 
hopelessly inadequate.216 Other mental health workers are similarly scarce. For example, 
at Mulawa Women's Prison in Sydney: 

There are no social workers or other kinds of ancillary staff that we'd like. There are
 two good psychologists at Mulawa and they work [well], but they have a very full load.217 

At Lithgow Corrections Centre, which is a much better appointed prison and the 
segregation facilities there are much more sensibly designed — the jail has been opened
 for six months, [and] there is still no psychologist. They have appointed a drug and alcohol worker.218 

The problem is by no means confined to NSW. In Queensland the Inquiry 
heard: 

The psychiatrists from the community psychiatry team go up to Lotus Glen [Prison]
 once a month, I think. There is a psychologist employed at Lotus Glen, but there are no programs219.

In Western Australia: 

The prison medical service is small and deals with minor health problems. As more
 mentally ill offenders are imprisoned, the system will increasingly fail to address 
the real issues associated with this group.220 

In Victoria the shortage is especially acute in the detention centres for young 
offenders: 

Human Rights and Equal Opportunity Commission Page 783 


We have about 250 young people in our youth training centres in this state, with one 
medical person who's specifically involved with their mental health.221 

The staff shortage in prisons is due to a lack of funding for positions; but even 
the positions which are funded are difficult to fill. Forensic psychiatry is not
 perceived as an attractive field of work,222 and the work environment is 
hardly alluring: 

Conditions are difficult for staff as well as prisoners, and qualified staff accept
 a much lower standard of conditions than their counterparts in the community.223 

Lack of Training for Police and Prison Staff 

Too many police are sent to stations without this knowledge — and even if they gain 
it, they are transferred [away] and the rapport is lost; and the people with mental
 illness and their families are left without any support once again.224 

The distress suffered by mentally ill people in the criminal justice system is 
made worse by the fact that most police and prison officers have no training in 
recognising or dealing with mental illness.225 Yet they are routinely the only 
people present when someone is taken into custody. Many police and prison 
officers are humane individuals who 'make a valiant effort to do what they 
can'226 — but they are not trained to deal with mentally ill or disturbed 
people. Given the potential seriousness of the consequences, the absence of 
training for these officers is a dangerous oversight which must be corrected. 

Additionally, in a society where mental health crisis teams are a rarity, police 
are frequently called specifically to deal with episodes of mental illness, even 
if no offence has been committed.227 These officers must assess whether an 
individual is likely to be dangerous, and if so how much force to employ in 
subduing or arresting the person. Sometimes they use too much force, causing 
further distress and humiliation for the mentally ill person and their family. 

Obviously they need training for these emergencies. The Inquiry was told that 
all Victoria's police now receive such training;228 clearly our other police 
forces should follow the Victorian example. 

Consequences of the Staff Shortage 

I think the longest list of prisoners I've been asked to see in any one visit is 27, which
 really doesn't allow for any more than band-aid psychiatric management.229 

For highly trained and committed professionals, the job satisfaction available 
in our prisons appears to be absolutely minimal. They have little contact with 

Page 784 Mental Illness Inquiry 

individual prisoners, very few resources and no say in the administrative fate 
of their patients.230 Notions like 'continuity of care', 'best available treatment' or 'the 
doctor-patient relationship' appear to be unknown to prison authorities. 

The concept of health workers being primarily concerned with the health of 
their patients is comprehensively overridden by the demands of penal administration: 

The institutional mental health professional at any one time is wearing two hats. He's wearing 
the hat of the person contracted to the institution...is containing [disruptive behaviour] and 
providing administrative answers — not necessarily acting entirely for the therapeutic benefit
 or value of the prisoner or patient. 

And the second hat we wear in delivering services is, in fact, to consider what illness the 
prisoner or patient exhibits and the most appropriate form of treatment. 

Now, I think a lot of the time we see ourselves operating in the second mode, whereas in actual
 fact we are operating in the first mode. And where there is a shortage of time to offer what
 I consider an adequacy of services, almost exclusively we're operating in the first mode and
 therefore treatments are actually not delivered.231 

Even prisoners identified as being 'in treatment' for mental illness have very 
little contact with their treating professionals. As one former inmate told the 
Inquiry: 

The treatment was absolutely minimal, perhaps ten minutes a fortnight for people such as myself
 who were needy, and almost nothing at all for [other] patients.232 

A further effect of the staff shortage is the potential denial to forensic patients of their 
legal rights. For example, in South Australia the law requires that involuntary hospital 
detention orders be issued and reviewed by different 
psychiatrists. But because of the shortage of forensic psychiatrists: 

it would be fair to say...that the same people are reviewing those orders and maintaining 
them on occasions... And the same person may be providing the assessment and also providing
the treatment.233 

Another legal consequence of the shortage was noted by the PMS Review 
Committee: 

The Committee has been informed of instances where prisoners appear before parole review
 hearings, and are refused parole on the basis that they have not undertaken appropriate 
psychiatric or psychological counselling.234 

Despite their extremely difficult conditions, the mental health staff who choose 
to work in our prison systems are capable and dedicated. When prisoners 

Human Rights and Equal Opportunity Commission Page 785 

actually get to see a mental health worker, they are often satisfied with their 
treatment: 

• My psychiatrist has given me the most help in my life, excellent. 
• I have had occasion to have assessment by Department psychologists and found these
 people very helpful. 
• I have seen three different psychiatrists/psychologists and they have all been most 
understanding and helpful. 
• We would like to see more of the psychiatrist please.235 A psychiatrist working in 
the NSW prison system told the Inquiry: 

The nursing staff in all of the ten years that I've been there have been of the very highest
 standard and calibre. My job has been made enormously more easy by their common sense and 
caring approaches and principles.256 

Country jails 

The shortage of staff — and thus the inadequacy of service — is especially 
acute in country jails. According to one psychiatrist: 

In the early 80s, I was visiting [Bathurst Gaol] once a week...probably offering four hours
 a week — I think up to 20 hours a month was my contract. Now, partly through the way the 
system has contracted, partly because of my own practice requirements, I travel to the 
country once a month and probably only go to Bathurst Gaol maybe ten times a year. And 
four hours, of course — even if it were ten hours a month, that is not enough time.237 

This witness told the Inquiry that he was the only consultant psychiatrist 
available to the Bathurst and Lithgow jails. At the time (mid 1991) there were 
over 650 prisoners in those two facilities,238 for whom he was available three 
days per month in total!239 

In NSW, where prisoners are all too easily transferred between jails at short 
notice, arranging a transfer from a country jail to the prison hospital in Sydney is difficult: 

Unless somebody is very crazy indeed, and of course I'm using that term in the lay 
sense, it is not easy to transfer them as an emergency... [There is] a resistance
 that crops up in maintaining what some of us in the country would see as a proper
flow, proper clinical care 240.

Page 786 Mental Illness Inquiry 

Release from Jail 

Often they leave prison without medication, though they may have been taking
 medication whilst in prison. And they are released often without any accommodation
 being arranged for them at all.241 

Prison systems are frequently criticised for failing to prevent crime because 
some inmates commit further offences after release into the community. The 
standard response from governments is to call for longer sentences and crack 
down on conditions, day leave, remissions and parole. This recent and 
increasingly strident emphasis on punishment clearly contravenes the Standard 
Minimum Rules' requirement for rehabilitation to receive appropriate emphasis. 

Rule 58. The purpose and justification of a sentence of imprisonment...is ultimately
 to protect society against crime. This end can only be achieved if the period of 
imprisonment is used to ensure, as far as possible, that upon his return to society 
the offender is not only willing but able to lead a law-abiding and self-supporting life. 

Rule 59. To this end, the institution should utilise all the remedial, educational, 
moral, spiritual and other forces and forms of assistance which are appropriate and
 available, and should seek to apply them according to the individual treatment needs
 of the prisoners.242 

These Rules recognise that punishment alone will not prevent re-offending; and 
that offenders should not be incarcerated in prisons which do not attempt to 
equip them for a self-supporting life. This is especially true for mentally ill 
offenders, for whom imprisonment actually reduces the chances of a self-
supporting life.243 

It seems a very obvious point — but one the evidence demonstrates is widely 
ignored; almost all prisoners are released eventually. If mental illness 
contributed to their breaking the law in the first place, and the illness is not 
treated, then it is very likely they will break the law again. 

Prison mental health staff are in a position to observe first-hand the failings of a 
system that makes no attempt to rehabilitate offenders, nor to establish even the 
most minimal safeguards which might prevent them coming back to jail. 
For example, NSW prison psychiatrists are not even informed when an inmate 
whom they are treating is about to be released or transferred to another jail: 

I have often just gone to find a patient to write up medication or something, and found
 that they have been released.244 

There are no case management plans, nor any system of notification. Whether 
a psychiatrist hears of an impending release 'depends on individual personalities working
 together,' i.e. on the goodwill of prison staff. The prisoners themselves 

Human Rights and Equal Opportunity Commission Page 787 

are not always notified of their release date in advance. Even if they know they 
are due for release, planning for aftercare is difficult because [Prisoners] don't always
 have the right information either, because there are complications 
about giving particular dates and sometimes they don't know what area they are going to 
live in.245 

The absence of a notification system implies a lack of respect in the penal 
system for the doctor-patient relationship. On a practical level, it also prevents 
psychiatrists making any follow-up arrangements for individuals who are often extremely
 vulnerable: as well as being mentally ill, they may have lost many of their social ties
 and coping skills while in prison. Discharge procedures at prisons (like psychiatric 
wards) are at times quite inappropriate. For example, a psychiatrist told the Inquiry 
of a prisoner suffering from 'schizophrenia and quite a lot of social disadvantage',
 who was released in the middle of the night: 

From this prison which is situated right in the middle of — well, a very long way
 from public transport anyway — with no money at 2.30 am, because [the prisoner] 
had a 48hour sentence and the 48 hours finished at 2.30 in the morning.246 

Obviously it would be unfair to keep inmates in prison for longer than their 
maximum sentence requires. But the alternative should not be release into a 
vacuum. If mental health workers in the prison system are notified, they can 
try to arrange some support for these prisoners to ease them back into the 
community. 

In Western Australia prison officers sometimes contact Outcare, a housing and 
support agency for ex-prisoners, before an inmate is released on parole. Having 
secure accommodation can be a prerequisite for parole being granted — but if 
none is found, prisoners will often be released anyway. Prisoners who have 
served their full sentences are generally released without such a referral being 
made.247 

Follow-Up after Jail 

I would say that in most of Sydney the follow-up of former prisoners either is inadequate
 or doesn't take place at all.248 

The lack of support for mentally ill people released from jail was one of the 
most common concerns raised in the Inquiry. Mental health service providers 
often discriminate against ex-prisoners (see below). But prison systems also 
make no provision for psychiatrists to arrange follow-up care for their patients 
on release. Concern about inmates' health, while minimal at the best of times, 
evaporates completely when they walk out the prison gates. 

Page 788 Mental Illness Inquiry 

Forensic psychiatrists who do try to maintain contact with their ex-patients are 
often obstructed by the corrective services culture itself. A psychiatrist who 
visits the NSW country jails said that if he makes a 15-20 minute STD phone 
call to check on a former patient, 'people start to ask questions' about the 
cost.249 

In October 1990, members of the forensic psychiatry section of the RANZCP 
wrote to the NSW Minister for Health expressing concern about the grave 
difficulties in securing psychiatric care for ex-prisoners, and especially for 
discharged forensic patients. One of those psychiatrists told the Inquiry there 
were about 500-600 prisoners on parole in NSW in need of psychiatric care, 
but most of them are probably not receiving it.250 Such a situation is shortsighted in the 
extreme; not only are the rights of sick individuals not observed — the rights of the wider 
community may well be imperilled. Apart from meeting the needs of prisoners, appropriate
 follow-up care can provide a means of reducing overcrowding: 

Any method of reducing the prison population is well worth looking into. And this is one 
method: that a number of psychiatrically ill prisoners could in fact be released, providing
 that appropriate psychiatric follow-up were available.251 

What Happens to Mentally 111 People Released from Jail? 

Mentally ill people released from jail often follow a path like that of people 
released from psychiatric hospital wards. However, they bear the additional stigma that
 goes with a criminal record. This makes it even harder to obtain the 
health care and other services they need: 

Either criminal behaviour or mental disorders, when viewed separately, create prejudices
 and rehabilitation difficulties. However, when clients have a history of both criminal
 and mental health issues, [they] tend to be shuffled from one agency or hostel to another...
 Whatever their pressing problem is at the time [determines] where they go.252 

Discrimination against offenders on the grounds of mental illness 

People coming out of jail frequently have no job, nowhere to live, and little 
social support. If they are also affected by mental illness, these problems are 
compounded by the inadequacy of the support available. For example, they 
have extreme difficulty in securing accommodation (see Chapter 10). 

In Perth a witness from Outcare told the Inquiry that ex-prisoners generally 
face discrimination in trying to rebuild their lives; but prejudice against mental 

Human Rights and Equal Opportunity Commission Page 789 

illness is greater still.253 As another witness who works with ex-prisoners in 
Melbourne said: 

It's easier to be forgiven if you're just bad. If you're mad and bad, you've got real problems.254 

The Outcare worker described a common reaction from support agencies approached to assist
 Outcare clients who are mentally ill: 

Initially, they are probably a bit put off about helping, because...they know we only 
deal with newly released prisoners. But once anything about mental illness is mentioned, 
they withdraw totally from providing any assistance.255 

Discrimination by mental health services against ex-prisoners 

If they endeavour to get services from agencies or institutions that provide assistance
 to people with psychiatric disabilities, the fact that they are ex-prisoners goes
 against them.256 

Mental health services themselves are not immune from prejudice. One of the 
reasons prison psychiatrists have considerable difficulty arranging follow-up 
care is that many community health services are reluctant to take on patients 
who bear a forensic label.257 (As mentioned previously, this reluctance can 
be the reason why a prisoner went to jail in the first place, instead of receiving
 a non-custodial sentence involving mandatory treatment.)258 

It is ironic to find such prejudice among mental health professionals, many of 
whom work hard to dispel the myth that mental illness equals violence. The 
idea that all ex-prisoners are dangerous is equally an overgeneralisation.259 

Some mental health services refuse assistance outright. Outcare cited this 
experience of trying to help a mentally ill prisoner about to be released: 

We approached the psychiatric hospital where he had most recently attended before he
 went to prison, and we were told that they were not prepared in any way to re-accept
 him, to provide outpatient follow-up support, nor to refer him to the community 
psychiatric division for accommodation... It was suggested that we organise accommodation 
for him in a single-sex hostel. However, when we checked the prisoner's [records], 
the same hospital had prepared a report indicating that this prisoner should not
 be released to unsupported accommodation.260 

This prisoner was released from jail with no supervision or medication 
program. He very soon re-offended and found himself back in prison.261 

Page 790 Mental Illness Inquiry 

In some parts of Australia prisoners can be released directly from jail to a 
psychiatric hospital, ostensibly to ease the transition to the community. 
However, hospitals may not understand how disabling the effects of incarceration 
itself are. The Outcare witness told the tragic story of a prisoner who, 
after 17 years in jail, was released to a hospital for 'resocialisation' — a one-week 
program. As well as being mentally ill, he was physically disabled and 
on medication for epilepsy. Within a very short time he was released into the 
community with no support structures in place. Outcare several times raised 
concerns with the hospital about the lack of support. Eventually he reoffended, 
served another short prison term and another stint in hospital, then drifted into 
a boarding house where he contracted pneumonia and died.262 

One solution for following up mentally ill inmates, described to the Inquiry by 
a forensic psychiatrist in Sydney, is for a few community mental health clinics 
to receive extra resources to develop a specialist expertise in caring for patients
 with a prison record. These centres would employ staff with experience of dealing 
with offenders. The Prison Medical Service would refer selected prisoners to the 
centres on release, thus ensuring continuity of care. The centres could also provide
 a consultative service to Probation and Parole Services.263 This proposal was put to 
the NSW Government in 1990, but no response was ever received. 

A version of this proposal operates in Melbourne, but it has its own shortcomings.
 The Parliament Place clinic is a psychiatric outpatient facility for people on 
probation or parole. But this focus on formal status in the penal 
system excludes ordinary prisoners who have been released after serving their 
full sentences: 

If you're not on a corrections order then you're really not eligible to use
 that particular service.264 

Probation and Parole 

The mental health system's refusal to treat ex-prisoners has adverse consequences
 for the prisoners' health and liberty. But it also creates deep discontent among 
workers in the criminal justice system, including probation and parole officers. 
These officers are charged with supervising offenders who are released conditionally
 into the community: either on parole (after serving part of a jail term) or on 
probation (instead of a jail term, eg a community service order or a bond). 

If the offenders have a mental illness, probation officers are often expected to 
seek treatment for them. According to the Probation and Parole Officers' 

Human Rights and Equal Opportunity Commission Page 791 

Association of NSW, this task is made 'difficult, if not almost impossible' by 
the health services' reluctance to take on these clients. The officers are thus 
left by default with a responsibility for which they have no training, and which 
they insist should be shouldered by the health sector rather than the penal system. 

The Association rejects the suggestion that the officers should merely be trained 
in how to supervise a mentally ill offender on parole: 

What is needed is better coordination with the Health Department, an increase in 
resources available for these people [mentally ill offenders] and for the health 
system to accept responsibility.265 

The officers' main concern is with prisoners who are floridly psychotic, aggressive
 or dangerous. In some cases the criminal justice system, recognising 
that jail is an inappropriate solution, will recommend hospitalisation of such 
offenders. However, such recommendations are hardly enforceable if the hospital 
takes a different view of the matter: 

A leading Sydney psychiatric hospital proposed discharging a long-term psychotic
patient on the grounds of lack of facilities for aggressive/dangerous patients. 
On a prior discharge, against family wishes, the patient had killed his mother. 
It took the coordination and intervention of both responsible Ministers to block 
the proposal.266 

On the other hand, court-ordered treatment can fail for more mundane reasons. 
Witnesses from the Epistle Post Release agency in Melbourne told the Inquiry 
of a young man with schizophrenia who, being 'quite a resourceful person', 
was able to get a job when released on parole. However, his parole conditions 
required him to attend the Parliament Place clinic, in the centre of Melbourne, 
to receive his medication. The clinic did not make out-cf-hours appointments. 
His job was in the outer suburbs, so he constantly had to leave work early to 
honour his appointments. If he did not attend, he was breaching his parole 
order; if he did, he was breaching his employment obligations. Epistle Post 
Release tried to get the parole conditions altered so that he might receive 
treatment closer to work; but before this could be resolved he gave up his 
job.267 

The Northern Territory Mental Health Service Forensic Team 

The Inquiry heard of one forensic psychiatry service which appears to have 
surmounted some of the bureaucratic obstacles to aftercare. The forensic team 
in the Northern Territory Mental Health Service 'operates at the interface 
between the health system, the criminal justice and corrections system. '268 It 
is a multidisciplinary team with a part-time consultant psychiatrist. It provides 
all forensic psychiatry services, including running security Ward 9 at Royal 

Page 792 Mental Illness Inquiry 

Darwin Hospital; assessing inmates at Darwin Prison and the juvenile detention 
centre, then making recommendations to the prison medical service about treatment;
 monitoring and counselling individual prisoners where necessary; training prison
 officers in mental health issues; and consulting to the courts during trials and
 at sentencing. In addition, the team provides a regular outpatient service for 
offenders. The existence of this service allows the Parole Board to grant parole,
 and the courts to order non-custodial sentences, on the condition that the offender
attend for treatment — and to be confident that the condition will be fulfilled.269 

Are Mentally Ill People Violent? 

It's important to recognise that nearly all the people who are discharged from 
psychiatric hospitals are just like everyone else. But there is a tiny number who 
are extremely dangerous and have a high recidivist rate in violent crime.270 

Discrimination against mentally ill people, especially if they have been to jail, 
is based largely on the public perception that these individuals must be violent. 
The evidence to the Inquiry overwhelmingly stressed that this view is greatly 
exaggerated. Not all ex-prisoners have a history of violence;271 nor does mental 
illness equate with violence.272 

The presumed link between violence and mental illness was described by one 
expert witness as 'a furphy and a red herring'.273 According to another: 

The facts of the matter are that most mentally ill people are not violent... 
There is a slightly higher proportion of violence amongst the mentally ill than 
amongst the non mentally ill. However... the strongest indicators of violence are 
age and sex... All [the] research indicates that we are at much greater risk of 
violence from males between the ages of 18 and 25 than we are from the mentally ill.274 

Do Mentally Ill Offenders Re-offend? 

All people released from prison without adequate support face the very real risk 
of reoffending. For those with any degree of mental illness this risk is compounded,
 not only by their health difficulties, but also by the lack of suitable community care.275 

Expert witnesses to the Inquiry agreed that mentally ill ex-prisoners are most 
likely to re-offend if they do not receive treatment and support after their 
release from jail.276 In the absence of appropriate aftercare, the 'revolving 
door syndrome' becomes established: 

They are released without any follow-up arrangements being made, and they turn
 up again a week or so later.277 

Human Rights and Equal Opportunity Commission Page 793 

Prisoners with a dual disability are doubly disadvantaged. The following 
account of an inmate with a mental illness and an intellectual disability was 
typical of several presented to the Inquiry: 

This was a young man serving a short prison sentence following a fairly trivial 
offence...and towards the end of the sentence we became aware that he had nowhere
 to live on leaving prison — that he'd essentially been living on the streets prior 
to the offence, and unless something was done quickly he would return to living on
 the streets. We wrote to the community mental health clinic which tries to provide
 a service including accommodation for the developmentally retarded; [but] they were 
not able to offer any help with accommodation. The man left prison, went back to the
 streets, and...re-offended within a matter of weeks, and simply came back to prison 
again.278 

The witness pointed out that each person in prison costs taxpayers at least 
$50,000 a year. As a form of housing for people affected by mental illness, this 
is a ludicrously expensive and unsatisfactory solution.279 From a human rights 
perspective it is repugnant. 

Prison vs. Hospital 

I've seen psychiatric facilities which are as dehumanising as any jail. On the other
 side of the coin, you see some prison facilities which are very modern in certain 
parts of the world...which emphasise aspects of human dignity.280 

Should offenders who are mentally ill be detained in the prison or the health 
system? Mental illness per se does not justify hospitalising a prisoner as an 
inpatient, any more than it does a person outside jail. One witness drew an 
analogy between prisoners living in the main jail and other mentally ill people 
living in the community: 

The majority of individuals with emotional or mental difficulties are cared for by
 the prison medical service, who are the equivalent of general practitioners. 
That mirrors the situation in the community at large where the majority of mental 
disorder is dealt with by non-specialist practitioners and only a small proportion
 enters into specialist psychiatric 281care.

Wherever people live they are entitled to the 'best available mental health care' 
(Mental Illness Principle 1.1). The prison medical services in most parts of Australia
 are clearly failing in this respect. 

All prison systems acknowledge there are some severely ill offenders who need 
hospital treatment. The question then becomes whether this should be provided 
in a prison hospital ('a hospital within a prison') or in a secure psychiatric ward 
of an ordinary civil hospital ('a prison within a hospital'). Both models are in use 
in Australia. 

Page 794 Mental illness Inquiry 

Apart from standards of care, both models raise the issue of competing rights. 
In an ordinary psychiatric hospital, the competition is between the rights of 
forensic and civil patients: 

It is a very difficult balance between the rights of individuals with mental illness
 to receive optimal treatment in the least restrictive environment...and the rights of
 those who have a mental illness and a co-existing criminal justice problem to receive
 optimal treatment.282 

In the prison system, the rights of mentally ill inmates compete with those of 
other prisoners, and of staff untrained to handle mental illness: 

Some [non mentally ill] inmates believe they are imprisoned in an institution for
 mentally disturbed people rather than a prison... We have observed increasing tensions
 in both staff and inmates.283 

The existence of a psychiatric ward within the prison system does not make it 
easy to obtain treatment for mental illness: as described above, transferring an 
inmate out of the cells and into the prison hospital can be extremely difficult. 
Standards of care in these wards are not immune to the effects of gross 
understaffing in prison medical services. The punitive atmosphere pervading 
corrective services is also unconducive to mental health. For these reasons the 
Inquiry takes the view that prisoners who become seriously mentally ill should 
be treated in the health care system, not a prison hospital. It is, after all, their
 right to receive the same standard of health care as other mentally ill people. 

Hospital Within a Prison 

Psychiatric wards inside prisons are found in Victoria (G-Division at Pent-
ridge), Queensland (Security Patients Hospital, Wacol Prison), and NSW 
(Malabar Psychiatric Unit at Long Bay). The Malabar unit was established to 
replace an old 'prison within a hospital', the forensic Ward 21 at Morisset 
Hospital near Newcastle.284 This was in response to recommendations by the 
Royal Commission into NSW Prisons, which was highly critical of conditions 
at Morisset.285 

Prison Within a Hospital 

In most Australian jurisdictions forensic psychiatry is treated as part of the 
health care system. South Australia switched to this approach when it closed its 
old 'hospital within a prison', Northfield Security Hospital at Yatala Labour 
Prison. It now has a specialist forensic psychiatry hospital, James Nash House, 
built in the grounds of Hillcrest Hospital and run by hospital staff.286 Hillcrest 
itself is now being closed, but the forensic unit will remain.287 

Human Rights and Equal Opportunity Commission Page 795 

Individuals from the criminal justice system are admitted [to James Nash] as either
 voluntary or detained patients, depending on their mental state, as any other citizen
 would be to a hospital. But because they're within the criminal justice system the legal
 convention is used that they are placed on special leave from the prison system...We have
 found [this] to be a successful strategy for ensuring that the custodial system retains 
an interest in these individuals, but that they are managed within the health care system.288 

Victoria also has three forensic wards in psychiatric hospitals, two at Mont 
Park and one at Aradale Hospital. 

Elsewhere, inmates affected by severe mental illness are transferred out to an 
ordinary secure ward in a public psychiatric hospital. This is the case, for 
example, in Western Australia (at Graylands Hospital), the Northern Territory 
(Royal Darwin Hospital's Ward 9), Tasmania (Royal Derwent Hospital) and for women prisoners
in Sydney (Cumberland Hospital). 

One problem with relying on transfers to the health system is that only a few 
beds are generally allocated for forensic patients. If those beds are full, the 
prisoner must remain in jail,289 or else: 

Sometimes we'd have to negotiate with a hospital to get a bed [for] someone with a mental 
illness who was a prisoner, and then we would have to get prison officers to come and stand 
outside the room.290 

Some witnesses to the Inquiry also objected to this transfer system, believing 
mentally ill offenders could pose a danger to ordinary patients in the hospital.291 On the 
other hand, the manager of forensic services in the Northern Territory told the Inquiry the 
two classes of patients are not so 
different from each other: 

In the majority of cases, civilian patients admitted to [Ward 9] have an extensive history
 of involvement in the criminal justice system, even if they are not currently involved.292 

Darwin's 'multi-purpose mental health facility' 

One option for hospitals which cannot afford to build an entirely separate 
forensic unit is Royal Darwin Hospital's proposal for a 'multi-purpose mental 
health facility'. This will be a high-security ward accommodating three groups 
of inpatients: civil acute patients, mentally ill prisoners and sexual offenders 
diagnosed as having personality disorders. The first purpose-built psychiatric 
facility in the Territory, it will replace Ward 9, the secure ward which currently takes
 all acute patients from throughout the jurisdiction. 

This proposal was the subject of a great deal of the evidence heard by the 
Inquiry in Darwin. A witness from the NT Association for Mental Health said: 

Page 796 Mental Illness Inquiry 

Relatives and friends of acute admission patients who have seen the plans are both appalled 
and distressed that their loved ones will be housed in such an integrated structure.29"1 

One objection is to the proposal's 'very dominant forensic ethos...[its] oppressive 
security-oriented design and surveillance systems'. Another is that non-forensic patients
 may be harmed by sharing facilities with prisoners, and their rehabilitation hindered 
by having to live in a highly restrictive, maximum 
security environment. The cost is very high — $7 million, which is equivalent to most
 of the mental health service's annual expenditure. In addition, the Association told
 the Inquiry that the community had not been adequately consulted in the planning process.294 

In response to these grievances, NT Government witnesses insisted that separation will 
be maintained between civil and forensic patients in the new 
unit. The three groups of patients will be accommodated in different wings, 
with common facilities like the gymnasium allocated for the use of each group 
at different times.295 The capital funding will be additional to the current 
mental health budget.296 

The government also maintains there is a need for an inpatient treatment 
program for sexual offenders: 

The sole aim of this program is to reduce the rate of re-offending in this group,
 and thereby reduce the number of children and women who would otherwise be abused 
and traumatised in the future.297 

As a result of the concerns raised during the Inquiry's visit to Darwin, the 
Government agreed to modify the proposal's design to provide, for example, 
separate entrances to each of the three wings. 

Governor's Pleasure Prisoners 

One of the worst things that could happen to anybody in this State is to be found
 not guilty of an offence on the grounds of mental illness.298 

The classic 'forensic patient' is an offender who goes to trial and pleads not 
guilty by reason of insanity.299 If the plea succeeds the accused is acquitted, 
but still kept in custody for mental health treatment 'at the Governor's pleasure'.
 The same occurs if the accused did not stand trial because mental 
illness rendered him or her unfit to plead. 

The purpose of the insanity defence is to recognise that mental illness can rob 
people of the capacity to understand what they are doing. Conviction for a crime 
requires that both the act itself and the requisite intent be proved. An 

Human Rights and Equal Opportunity Commission Page 797 

acquittal on the grounds of mental illness means the accused person committed 
the criminal act, but cannot be held responsible for it. 

This solution appears to emphasise treatment rather than punishment of the 
offender. However, the purpose of Governor's pleasure detention is not treatment,
 but only protection of the public.300 In reality, such detention can 
be a particularly severe punishment because it is not subject to the normal
 legal protections which apply to those convicted of crimes. 

The most obvious disadvantage of Governor's pleasure detention is that it is 
indeterminate.301 An ordinary prison term is proportional to the offence 
committed and its maximum duration is clearly stated by the sentencing judge. 
By contrast, Governor's pleasure detainees have no idea when they can expect 
to be released. In fact, their detention can turn out to be much longer than 
they would have served if they had actually been convicted:302 

I give as an example a 23-year-old mentally retarded invalid pensioner charged 
with aggravated burglary...[who] was permanently unfit to plead... He was
 committed to the prison in April 1985, having already been in custody two 
months. It was not until a year later that he applied through the efforts of 
the prison psychiatrist for transfer or release. It [then] took some months 
before the tribunal secured his release.303 

Governor's pleasure cases are reviewed regularly by an advisory body,304 but 
it is the executive government which makes any decisions about a detainee's 
release or continued detention, and about treatment, transfer in or out of 
hospital, and fitness to be tried. Several expert witnesses told the Inquiry that 
this use of executive discretion sometimes produces serious injustices. 

The Review 

Forensic patients' 'rights' in the review process vary widely from State to 
State. In NSW, the Mental Health Review Tribunal reviews cases every six 
months; the patient may give evidence to the Tribunal and normally has legal 
representation. However, neither the patient's evidence nor the lawyer's 
submissions are transcribed or passed on to the ultimate decision-maker.305 

In Tasmania the Tribunal is specifically exempted, where the patient being 
reviewed is a prisoner, from its normal requirement to give reasons for an 
adverse recommendation.306 

In Victoria the review is conducted by the Adult Parole Board once a year, and 
patients have 

Page 798 Mental Illness Inquiry 

no right of appearance before the Board, no right to make any submissions, no
 right to be informed of the matters which the Board takes into account. Often
 the material which is placed before that Board is coordinated by parole officers 
and not by qualified medical practitioners.307 

In Western Australia the review is also conducted by the Parole Board, which 
under statute is specifically exempted from requirements of natural justice.308 
An expert witness in that State called this 'the very antithesis of a judicial 
procedure'.309 

The Decision 

A review body can recommend to its executive government that a detainee is 
no longer dangerous and should be released. However, the executive can accept 
or reject the recommendation. In Victoria the recommendation goes to the 
Attorney-General: 

Again the patient has no right of appearance, no right to be informed of materials
 which are placed before the Attorney-General, and no right of questioning anyone
 who might be saying anything adverse to their interests.310 

The matter then goes to Cabinet, where (still without the patient having had any 
involvement) the decision is made. The president of the Victorian Mental 
Health Review Board told the Inquiry: 

That system is simply terribly wrong and terribly unfair.311 

In NSW the decision-maker is the Minister for Health: 

No reasons have to be given by the Minister if he chooses not to accept the
 [Tribunal's] recommendations, and therefore the patient has no opportunity
to address any fresh concerns or correct apprehensions of fact with which he 
or she disagrees.312 

As well as being unfair, it seems likely that this process would result in poor 
quality decisions — since very little information is provided to the decision maker.
 In NSW, for example, the Tribunal supplies the Health Minister with 
brief written reasons for any release recommendation. Based entirely on this 
information, the Minister alone must decide whether transferring or releasing 
the patient would pose too great a danger to the community. Clearly this 
assessment would be more competently made by an expert body which has had 
the benefit of hearing the evidence.313 

Perhaps mindful of how poorly equipped they are for the task, decision-makers 
tend to make very conservative assessments. The impression of witnesses who 
gave evidence on this topic was that regardless of what the advisory body 

Human Rights and Equal Opportunity Commission Page 799 

recommends, the decision-makers generally decide against release.314 A 
Tasmanian witness said that even where the recommendation is merely to 
transfer a patient from prison to hospital, about half the time it is refused.315 
It seems improbable that such decisions are always based on a rational assessment
 of the prisoner's potential threat to the rights of the wider community. The
 prime criterion is sometimes the potential for political damage to a government 
perceived by the public as being soft on criminals:316 

The Minister, if he's got any sense, is going to think about votes — and it's 
easier to play it safe than to let someone go.317 

Apart from the consequences for individual patients, this outcome undermines 
confidence in the legal process and insults the expert members of the advisory 
bodies. The Committee reviewing the NSW Mental Health Act observed that if the 
Tribunal judges patients to be no longer dangerous, as persons found not guilty 
[by reason of mental illness] they are entitled to their liberty. To effectively 
impose a sentence of an unspecified additional period...makes a mockery of both 
the verdict and the review system.318 

One witness to the Inquiry was an eminent Tasmanian psychiatrist who publicly 
resigned from that State's Tribunal in protest over this issue.319 

International Human Rights 

Article 9(4) of the ICCPR requires that anyone in detention be able to seek 
review of that detention by a court. This should mean that a prisoner who is 
recommended for release by an expert tribunal, but kept in custody by the 
executive rejecting that recommendation, can apply for judicial review. 
However, the High Court of Australia has held there is no obligation on the 
executive to follow the tribunal's advice: 

The executive council can ignore that recommendation, and can do so on the grounds
 of what has been termed 'high level political responsibility'.320 

Effectively this means there is no judicial review of the decision to keep in 
custody a person who a) was legally acquitted in the first place; b) is deemed 
by the advisory body to be no longer dangerous or even mentally ill; and c) has 
already spent more time in custody than he or she would have if convicted. 

One witness pointed out the irony of blatantly political decisions being accepted in
 this area, at a time when the general trend is to de-politicise the administration of
 criminal justice.321 In his opinion this practice also breaches Article 9(1) of the
ICCPR, which requires freedom from arbitrary detention: 

Page 800 Mental Illness Inquiry 
'Arbitrary', in this sense, must necessarily mean where the detention is ordered by an
 entity...that is not an entity that gathers and sifts the facts, [ie] a non-judicial
 determination. In fact, the notion of Governor's pleasure detention has been referred
 to, quite rightly in my submission, as political detention of those who are mentally
 ill at the time of commission of their offences.322 

The United Kingdom, which gave Australia its Governor's pleasure system, 
was taken to the European Court of Human Rights in 1983 for these same 
breaches of international law.323 As a result the UK changed its law, giving 
the Mental Health Review Tribunal the power to order the release of an 
offender whom it considers no longer mentally disordered or dangerous.324 
The wishes of the executive (i.e. of the Home Secretary) must still be considered,
 but the detainee also has the chance to refute them.325 

The human rights principle is clear: an individual's liberty should only be 
denied by a judicial determination, not an unfettered and sometimes secretive 
political decision. As for danger to the public, evaluation of the Tribunal's 
decisions since 1983 has found: 

The Tribunal is no better, and in fact no worse, than the Home Secretary in terms of 
the right number of decisions as to release. In other words...the chances of making
 an incorrect decision are the same whether it is the Home Secretary or the Tribunal
 itself.326 

Apart from Article 9, two other human rights are endangered by the executive 
discretion to extend detention of a person judged to be no longer mentally ill. 
Article 10(1) of the ICCPR requires that people deprived of their liberty be 
treated with humanity; Article 7 prohibits cruel, inhuman or degrading 
treatment. The Inquiry was told it is cruel, inhuman and degrading treatment 
to detain in a mental hospital a person who is no longer mentally ill.327 This 
view has also received recent support from the European Court of Human 
Rights,328 and from the English Court of Appeal.329 

Avoidance of the Defence 

The practical consequence of all these drawbacks, according to evidence 
presented to the Inquiry, is that the insanity defence 'is almost universally 
rejected' by people accused of major crimes. Even if they are mentally ill, their lawyers 
advise that 'it is worse for their clients to [chance] the Mental Health Review Tribunal 
than to face a custodial sentence.'330 This means some 
people are convicted who otherwise may well have been found not guilty; it 
also means people whose greatest need is for psychiatric treatment prejudice 
their chance of receiving it; and it obscures the role that mental illness plays as a 
contributing factor in offences being committed. In addition, it leads to 
second guessing in the courts. Sometimes the sentencing judge will see mental 

Human Rights and Equal Opportunity Commission Page 801 

illness as a mitigating factor to take into account in sentencing.331 On the 
other hand, the defendant may be disadvantaged: 

The judges will see that a person has avoided a mental illness defence because that is likely
 to lead to longer confinement... But at the same time, the judges realise how potentially 
dangerous that person is. They have the reports of the psychiatrist who interviewed him, and
 so they tend to move towards something that is perhaps harsher in the long run than if [he]
 were treated under a well-balanced mental health review system.332 

Abandoning the Executive Discretion 

Several reviews and inquiries in Australia have urged that procedures for 
dealing with mentally ill offenders be overhauled. One important reform is die 
abolition of Governor's pleasure detention, or at least executive discretion in 
the disposition of these patients. Instead, an expert body such as a Mental 
Health Review Tribunal should have the power to order their release — as is 
the case in the UK.333 No Australian jurisdiction has yet taken this step. 

Other reforms need to be implemented to give the police and the courts more 
flexibility in the apprehension, remand or sentencing of people who are 
mentally ill or disordered — to allow and encourage non-custodial treatment 
rather than detention.334 Effective action must be taken to bring this area of 
our mental health and legal systems into line with the accepted international and domestic legal 
principles of natural justice and human rights. 

Personality Disorders 

Expert witnesses from forensic mental health services referred frequently to 
'behavioural' or 'personality disorders'. These conditions do not qualify as 
mental illnesses under mental health legislation335 — even though they are listed as psychiatric
 disorders in the standard diagnostic tool, DSM-III-R. Thus 
an individual diagnosed with a personality disorder cannot be hospitalised as an 
involuntary patient; cannot rely on the defence of insanity in a criminal 
trial;336 and will often be turned away by psychiatric hospitals and crisis services. 

Yet personality disorder is the single most common diagnosis among patients 
seen by prison psychiatrists.338 It is also among the most serious conditions, 
in terms of the risk of physical harm. People with personality disorders often 
engage in self-mutilation; in fact the symptoms can be as horrifying and 
dangerous as any psychosis: 

If you've got a personality disorder to the extent that...you're cutting bits off yourself, 
mutilating yourself, chopping fingers off, defecating, throwing urine...growling, and 

Page 802 Mental Illness Inquiry 

basically very uncontrollable — then if you're not deemed to have a mental illness and somebody who
 may have a well-controlled chronic delusion is deemed to be mentally ill, then there is some sort
 of perversity in that.335 

It is not only the patient who is at risk: personality disorder is often associated with actual or
 threatened crimes against others.340 This may be one reason why so many people with personality 
disorders are found in jail. 

The mental health system's refusal to treat personality disorders causes 
frustration, bewilderment and anger among people whose work brings them in 
contact with the individuals affected. Police, prison officers, probation and 
parole officers, prison psychiatrists, refuge and shelter workers see the consequences as the same
 individuals move through their services, often creating 
extensive disruption, then move on without receiving any treatment at all — 
only to reappear later: 

We have a number of long-term clients on our records who constantly repeat the same pattern of 
behaviour and the same pattern of referral: they are referred to public hospitals for observation
 and assessment; then they go to Graylands [Hospital] where the diagnosis is generally that they are
 of mixed anti-social personality disorders. They move between the hostels, lodging houses, Graylands
 and back to the prison system.341 

The Inquiry was told the refusal to treat personality disorders is based on a 
belief that these disorders cannot be treated.342 The Inquiry was also told this 
is not true:343 

This group is notoriously difficult to treat, and frequently require management rather than just
 treatment... [The] reluctance by psychiatric professionals to treat such people [is] because of
 the length of time and amount of resources required.344 

Treating personality disorders is costly and time-consuming, because it requires 
behavioural programs rather than medication. However, as well as the time and 
cost involved, one expert witness suggested another reason why hospitals reject 
these patients — prejudice against prisoners: 

In many psychiatric hospitals, 'personality disorder' is the label assigned to virtually any patient
 who comes from the criminal justice system. They write that on the file to justify sending them back
 to prison.345 

Often patients rejected on this basis are also being denied treatment (or early 
intervention) for a 'recognised' mental illness, which may accompany or follow 
a personality disorder.346 Because they are frequent reoffenders, they often 
develop a third problem which overlays and aggravates the first two: destructive 
behavioural patterns as a result of long-term institutionalisation in prisons:347 

Human Rights and Equal Opportunity Commission Page 803 

I haven't got a personality disorder...I call it a social disorder. I haven't learnt skills like 
paying taxes or catching trams.348 

It's obvious that a lot of the outbursts.. .are affected by environmental factors. The fact [is] 
that he is in the prison service and he has learnt behaviours. We feel these behaviours will
 have to be untaught and he will have to be re-educated...back into society.349 

Given the size of the problem, and the severe impact that people with 
personality disorders often have on their families, the wider community, 
welfare agencies and the prisons, it is essential that this unjustifiable stand-off between the
 health and prison sectors is resolved: 

Management of people suffering from personality or behavioural disorders requires cooperation 
from a number of agencies including Health, Police, Corrections, Alcohol and Drug authorities 
and Community Services. There is a need for joint initiatives to ensure that the rights of these 
individuals and the community are upheld.350 

Conclusion 

The Inquiry recognises that several of the issues raised in this chapter are 
complex and present difficult questions of both policy and practice. However, 
the human rights abuses currently being committed against people affected by 
mental illness in remand and correctional facilities cannot be allowed to 
continue. Australia has undertaken to honour certain standards clearly set out 
in a range of international instruments — and these obligations must be 
honoured. 

Page 804 Mental Illness Inquiry 

1. Robin Gurr, President, NSW Council of Social Services. Oral evidence, Sydney 17.6.91, p78. 
2. In some jurisdictions, including NSW, the definition also includes some prisoners who have a 
developmental disability. Robert Hayes et al, A Profile of Forensic Patients in New South Wales 
and an Assessment of the Role of the Mental Health Review Tribunal in Effecting Their Release, 
Mental Health Review Tribunal, 1991, pi. 
3. Dr David Ben-Tovin, Director of Mental Health Services, South Australia. Oral evidence, Adelaide 
22.10.91, p219. 
4. Hayes et al, op cit, pi. These 86 comprised: 65 found not guilty on the grounds of mental illness,
 9 unfit to be tried, and 12 who had been transferred out to a psychiatric hospital ward, having been
 diagnosed as mentally ill while in prison. 
5. NSW Department of Corrective Services, 'Weekly states for the week ending 27 October 1991'. 
6. Ben-Tovin, op cit, p219. 
7. The exception is Victoria: see the section of this chapter on assessment. 
8. Marion Leach, Outcare Civil Rehabilitation Council of Western Australia. Submission, p3. The same 
view was expressed by Sister Bernadine Daly, Sister of Mercy and prison visitor. Submission. 
9. A US survey of the research found an extraordinary range of prevalence: from 5 percent with 'psychosis'
 to 75 percent with schizophrenia. Linda Teplin, 'The prevalence of severe mental disorder among male 
urban jail detainees: Comparison with the Epidemiologic Catchment Area Program,' American Journal of 
Public Health, June 1990, v80, n6, p669. The disparities are partly due to methodological variations:
 some studies (and some jails) take random samples of prisoners, while others focus on inmates on 
remand or those referred for psychiatric assessment. Another inconsistency is in the criteria used to define 
a mental illness or disorder: many studies count substance dependency as a mental disorder, while 
others do not. 
10. id. 
11. Helen Herrman, Patrick McGorry, Jennifer Mills and Bruce Singh, 'Hidden severe psychiatric morbidity 
in sentenced prisoners: An Australian study', American Journal of Psychiatry 148:2, Feb 1991, pp236-9. 
12. Dr Yvonne Skinner, consultant psychiatrist to the NSW Prison Medical Service. Oral evidence, 
Sydney 8.7.91, p669. 
13. Dr Yvonne Skinner. Submission, pi. Also Libby Steeper, Mental Health Task Force, ACT Council for Social
 Service. Submission, p2. 
14. Prof Ivor Jones, University of Tasmania. Oral evidence, Devonport 14.11.91, pp426-7. 
15. ibid, p427. A Sydney psychiatrist also confirmed that the rate of mental illness is especially high
 among women prisoners: Skinner, op cit (oral evidence), p668. 
16. Prof Brent Waters, Department of Children and Adolescent Psychiatry, Prince of Wales Hospital. 
Oral evidence, Sydney 17.6.91, p29. 
17. Dr Hugh Jolly, consultant psychiatrist to the NSW Prison Medical Service. Oral evidence, Sydney 8.7.91, p647. 
18. Dr Ronald Barr, forensic psychiatrist. Oral evidence, Sydney 20.6.91, p421. 
19. Name withheld, Schizophrenia Fellowship of Queensland. Submission No440, p30. 
20. Steeper, op cit, p2. 

Human Rights and Equal Opportunity Commission Page 805 

21. Dr Joan Ridley, Director, Northern Territory Mental Health Services. Oral evidence, Darwin 21.7.92, pl30. 
22. D McDonald and C Howlett, 'Australian Deaths in Custody 1990 and 1991', Deaths in Custody Australia
 Nol, Australian Institute of Criminology, Oct 1992, p8. 
23. Leslie Wightman, Consumer Advocacy Program. Oral evidence, Adelaide 22.10.91, p212. Also Assoc Prof 
Joseph Reser, Department of Psychology, James Cook University. Oral evidence, Townsville 13.8.91, ppl274-5. 
24. Jolly, op cit, p655. 
25. ibid, pp649, 655. 
26. Skinner, op cit (submission), pi. 
27. id. Also Peter Mels, manager, forensic team, Northern Territory Mental Health Services.
 Oral evidence, Darwin 21.7.92, pl23. 
28. Herrman et al, op cit; Jones op cit, p427. 
29. Skinner, op cit (submission), pi. 
30. Herrman et al, op cit, p236. 
31. Jones, op cit, p427. 
32. id. 
33. Dr John Ellard, NSW Branch President, RANZCP. Oral evidence, Sydney 17.6.91, p69. 
34. Skinner, op cit (submission), pi. 
35. Ridley, op cit, pl30; Mels, op cit, pl23. 
36. Peter Chivers, ACT Housing and Community Services Bureau. Submission, pi. 
37. Name withheld. Oral evidence, Newcastle 9.7.91, p845. 
38. Dr Rod Milton, forensic psychiatrist. Oral evidence, Sydney 8.7.91, p686. 
39. Name withheld. Submission No391, pi. 
40. Dr Marie Bashir, Director, Central Sydney Area Health Service. Oral evidence, Sydney 20.6.91, p505. 
41. Judy Andrews, Far North Queensland Families and Prisoners Support. Oral evidence, Cairns 9.8.91, pll26. 
42. Leach, op cit, p3. Also Dr Geoff Smith, Director of Policy and Planning, Mental Health Services, WA Health 
Department. Oral evidence, Perth 12.2.92, p412. Also Orme Hodgson, Schizophrenia Fellowship of South Queensland. Submission, pl7. 
43. Karen Abram and Linda Teplin, 'Co-occurring disorders among mentally ill jail detainees', American
 Psychologist, Oct 1991, pi042. 
44. Andrews, op cit, pi 126. 
45. Hodgson, op cit, pl8. 
46. Dr Yvonne Skinner pointed out that illiteracy is fairly common among the mentally ill; some people
 receive fine notices or bills in the mail and simply put them aside because they cannot read them. 
(Information provided to the Inquiry after the close of formal hearings.) In 1988 NSW introduced a scheme 
to keep fine-defaulters out of prison, following the near-fatal bashing of a young defaulter, Jamie Partlic.
 However, the scheme has been declining steadily since 1989, and people now regularly go to jail in NSW for 
non-payment. Ivan Potas, 'The Sentencing Act 1989: Impact and review', in (1992) 3(3) Current Issues in 
Criminal Justice 318-328, p321. 
47. Leach, op cit, p3. 

Page 806 Mental Illness Inquiry 

48. Sun Herald, 28 March 1993. 
49. Dr Jenny Thompson, Forensic Study Group, RANZCP. Submission, pi. 
50. Skinner, op cit (oral evidence), p663. 
51. Kay Lancefield, Epistle Post Release Service. Oral evidence, Melbourne 8.4.91, pl47. 
52. Father Peter Nordan and Bernie Geary, Brosnan Centre Youth Service, Catholic Prison Ministry.
Oral evidence, Melbourne 9.4.91, pp292-3. 
53. Barr, op cit, p423. 
54. Robin Banks, Disability Advocacy Service, Alice Springs. Submission, p2. 
55. ibid, p6. 
56. John Hopkins, Disability Services of Central Australia. Quoted in Banks, op cit, Attachment 1, p6. 
57. Andrews, op cit, pi 129. 
58. Name withheld. Oral evidence, Townsville 13.8.91, pl305. 
59. Andrews, op cit, pi 128. 
60. Jolly, op cit, p25. 
61. Dr J Opie, Australian Catholic Health Care Association. Submission, p7. 
62. Name withheld. Submission No391, pi. 
63. Nordan, op cit, p299. 
64. Daly, op cit, p2. 
65. Eg Report of the Royal Commission into New South Wales Prisons, Government Printer, Sydney 1978; 
Australian Law Reform Commission, Sentencing, AGPS, Canberra 1988; Australian Law Reform Commission, 
Sentencing: Prisons, AGPS, Canberra 1987; G Hawkins, Prisoners' Rights, Human Rights Commission Occasional
 Paper No 12, AGPS, Canberra 1986; G Zdenkowski, 'Review of disciplinary proceedings in Australian Prisons', 
(1983) 7 Criminal Law Journal 3; G Zdenkowski and D Brown, The Prison Struggle, Penguin 1982; D Brown,
 'Putting the value back in punishment,' (1990) 15 Legal Service Bulletin 239; S Hatty (ed), Women in 
the Prison System, Australian Institute of Criminology, Canberra 1984; R Harding and W Cramond, Report 
of Inquiry into the Appropriate Treatment of Mentally III and Intellectually Handicapped Offenders, WA
 Department of Prisons and Health, Perth 1985; Report of the NSW Women in Prison Task Force, March 1985;
 Robyn Read MP, Elizabeth Kirkby MLC, Dawn Fraser MP and John Hatton MP, Report on Prisons Following Visits 
to Bathurst, Goulburn and Parklea Gaols, Nov 1990; Royal Commission into Aboriginal Deaths 
in Custody, AGPS, Canberra 1991; Report of the NSW Prison Medical Service Review Committee (PMS Review), 
NSW Health Department, Aug 1991; Amnesty International, Australia: A criminal justice system weighted against 
Aboriginal people, Jan 1993. The Human Rights Commissioner has objected on many occasions to prison conditions. 
However, these representations have met with considerable opposition from several State Governments. 
66. Another contender is Alice Springs Prison, which was singled out in Amnesty's report for 'conditions
 which could well be judged unacceptable according to international standards'. Amnesty International, 
op cit, pll. Amnesty concluded that conditions in some Australian prisons could amount to 'cruel, 
inhuman or degrading treatment' — the terminology used in the UN Convention Against Torture (Article 3),
 the Body of Principles for the Protection of All Persons Under Any Form of Detention or Imprisonment 
(Principle 6), and the Universal Declaration of Human Rights (Article 5). Its delegation 'observed extremely
 varied conditions...ranging from the excellent to the quite bad'. One of the 

Human Rights and Equal Opportunity Commission Page 807 

worst conditions was gross overcrowding in cells — eg in one wing of Long Bay Gaol in Sydney, prisoners were
 living three to a cell measuring about 3m by 2.2m. (However, prisoners in that wing were only confined to 
their cells for eight hours at night.) Of course, Amnesty was considering prison conditions from the point
 of view of ordinary prisoners who are not mentally ill. Those affected by mental illness are even more 
needy and less able to cope with hardship. 

67. Barr, op cit, p421. Also Skinner, op cit (oral evidence), p670. This concern about NSW prisons is borne out
 in the academic literature. For example at Parklea Prison, which was designed to house 210 inmates, the population
 in mid 1991 was 350. Angela Gorter, 'Impact of the Sentencing Act 1989 on the NSW prison population', 
(1992) 3(3) Current Issues in Criminal Justice, 308-317, p312. 
68. John Walker, Australian Prisoners 1991, Australian Institute of Criminology, Canberra 1992, pl7. 
69. id, pl09. 
70. Barr, op cit, p421; Skinner, op cit (oral evidence), p670. The Sentencing Act 1989 abolished remissions and 
aimed to ensure 'truth in sentencing'. As a consequence, fewer offenders now receive non-custodial sentences 
(eg community service) and those who go to jail are imprisoned for longer. Gorter, op cit, p317. 
71. Skinner, op cit (oral evidence), p670. 
72. ibid, p665. 
73. Robyn Read, Elizabeth Kirkby, Dawn Fraser and John Hatton, Report on Prisons 
Following Visits to Bathurst, Goulbum and Parklea Gaols (Independents' Report), Nov 1990. Submitted to the Inquiry
 by the NSW Prisons Coalition. p40. 
74. ibid, pp7, 57. David Brown, 'The state of NSW prisons: Crisis — what crisis?' Paper to the Australian 
Sociological Association Conference, University of Queensland, 15 Dec 1990, pi 1. 
75. Eg Lenore Nicklin, 'Yabbers takes up the cleaver,' Bulletin 2 Oct 1990; Richard Glover, Sydney Morning Herald 
14 Sept 1990. 
76. Skinner, op cit (oral evidence), p665. The official policy was to allow each prisoner six photographs, but its 
interpretation was left to individual prison governors, some of whom took an especially harsh approach. 
77. NSW Prisons Coalition. Submission, p44. 
78. Skinner, op cit (oral evidence), p665. 
79. ibid, p666. 
80. id. 
81. NSW Prisons Coalition, op cit, p45. 
82. id. 
83. Report of the NSW Prison Medical Service Review Committee (PMS Review), NSW Health Department, August 1991, pi 16. 
84. id. 
85. Ellard, op cit, p66. Also Skinner, op cit (submission), p4. 
86. Steeper, op cit, p3. 
87. NSW Attorney General and Minister for Justice, 'New property policy for NSW inmates'. Press release, 30 Aug 1993. 
88. Daly, op cit, p3. 

Page 808 Mental Illness Inquiry 

89. Dr Warwick Middleton, RANZCP Queensland Branch. Oral evidence, Brisbane 14.8.91, pl355. 
90. Skinner, op cit (submission), p4. 
91. Jolly, op cit, p648. 
92. Standard Minimum Rule 37, cited by Jolly, op cit, p648. 
93. Independents' Report, op cit, pp20,32,55. 
94. NSW Prisons Coalition. Information provided to the Inquiry after the close of formal hearings. 
95. Skinner, op cit, p666. 
96. Dr David Wells, Police Surgeon and Director of Forensic Medicine, Victoria Police. Submission, p3. 
97. Skinner, op cit (submission), p2; Daly, op cit, pi; Hodgson, op cit, pl8. 
98. Steeper, op cit, p3. 
99. Amnesty International, op cit, ppll-12. 
100. ibid, p5. 
101. Banks, op cit, pi. 
102. Wells, op cit, p3. 
103. Legal Aid Commission of Victoria, 'Custody in Police Cells — A Report', 1993, pi. 
104. ibid, p2. 
105. id. 
106. id. 
107. ibid, p3. 
108. Amnesty International, op cit, p8. 
109. id. Similar criticism could apply to the lock-up at Sydney Central Police Station, built in 1987 to accommodate up 
to 150 inmates. All the cells are underground, ibid, p9. 
110. Name withheld, op cit endnote 58, pl305. 
111. Standard Minimum Rule 22(1), cited by Jolly, op cit, p647. 
112. Ursula Dahl, former executive officer, Management Assessment Panel, SA Health Commission. Oral evidence,
 Adelaide 23.10.91, p405. 
113. NSW Prisons (Administration) Regulation, clause 11. Quoted in PMS Review, op cit, pl08. 
114. PMS Review, op cit, pl08. 
115. Thompson, op cit, p2. 
116. Barr, op cit, p423. 
117. PMS Review, op cit, pl09. 
118. Nordan, op cit, p293. 
119. id. 
120. id. 
121. Gurr, op cit, p78. 
122. D McDonald, 'National Police Custody Survey 1992: Preliminary Report', Deaths in Custody Australia No2, Australian 
Institute of Criminology, March 1993, p2. 

Human Rights and Equal Opportunity Commission Page 809 

123. NSW Police Service Custody Manual, paragraph 1.104, quoted in David Landa, Inquiry into the circumstances surrounding the 
injuries suffered by Angus Rigg in police custody and into the subsequent police investigations, Ombudsman's report to the 
NSW Parliament, Jan 1993, pill . 
124. McDonald and Howlett, op cit, p8. 
125. Dr David Wells, Police Surgeon and Director of Forensic Medicine, Victoria Police. Oral evidence, Ballarat 11.4.91, p595. 
126. ibid, p594. 
127. Wells, op cit (submission), p2. 
128. Landa, op cit, pl30. 
129. Andrews, op cit, pll25. 
130. id. 
131. Royal Commission into Aboriginal Deaths in Custody, Interim Report, p45. 
132. Landa, op cit, pl31. 
133. PMS Review, pl08. 
134. Jolly, op cit, p650. 
135. Hodgson, op cit, pl8. 
136. Nordan, op cit, p299. 
137. Skinner, op cit (oral evidence), p659-60. Since this evidence was given, a toilet has been installed. In Victorian jails 
the special isolation cells are called 'wet cells' — because they can be hosed down for cleaning. Geary, op cit, p299. 
138. Dahl, op cit, p406. 
139. Leach, op cit, p2. 
140. Marion Leach, Outcare Civil Rehabilitation Council of Western Australia. Oral evidence, Perth 10.2.92, p50. A 
similar report came from a former inmate in Queensland. Name withheld, op cit endnote 58, pl299. See also Skinner, op 
cit (submission), pl6. 
141. Name withheld. Submission No440, p30. 
142. Name withheld. Submission No45, pi. 
143. Ian Campbell, Mental Disorder and Criminal Law in Australia and New Zealand, Butterworths 1988, pl89. 
144. Dr Joan Lawrence, senior psychiatrist, Royal Brisbane Hospital. Oral evidence, Brisbane 16.8.91, pl745. 
145. Name withheld, op cit endnote 58, pl300. 
146. Hodgson, op cit, pl8. 
147. Jolly, op cit, p652. Also Nordan, op cit, p290. 
148. McDonald, op cit, p2. 
149. Amnesty International, op cit, p7. 
150. Andrews, op cit, pi 126. 
151. Name withheld. Submission No45. 
152. Andrews, op cit, pi 127. 
153. Name withheld. Submission No45, p6. 
154. She believes there is doubt about whether her son's death was a suicide. 

Page 810 Mental Illness Inquiry 

155. id. 
156. Standard Minimum Rule 82(1). 
157. Libby Steeper, Mental Health Task Force, ACT Council for Social Service. Oral evidence, Canberra 18.3.92, p30. 
158. Chivers, op cit, pi. 
159. Dr Russell Pargiter, consultant psychiatrist. Oral evidence, Hobart 12.11.91, pl49. 
160. Ted Watson, Incarcerated People's Cultural & Heritage Aboriginal Corporation. Oral evidence, Brisbane 15.8.91, pl529. 
161. NSW Mental Health Act Implementation Monitoring Committee, Report to the Hon R A Phillips MP, Minister for Health, 
on the NSW Mental Health Act 1990, Aug 1992, p39. 
162. Skinner, op cit (submission), pi. 
163. Walker, op cit, pl7. In 1991 there were about 730 women in Australian jails, out of a total of 15,000 prisoners. 
About 400 of those female inmates were in NSW. 
164. Skinner, op cit (oral evidence), p668. 
165. Skinner, op cit (submission), p5. 
166. ibid, pl6. 
167. ibid, pl5. 
168. 'Most have children and few are married or have a stable relationship (less than 10 percent).' ibid, p5. 
169. id. 
170. Skinner, op cit (oral evidence), p668. 
171. Jones, op cit, p427. 
172. ibid, p428. 
173. ibid, p427. 
174. Skinner, op cit (submission), p2. 
175. See endnotes 68 and 71. 
176. Skinner, op cit (oral evidence), p667. 
177. id; also Skinner, op cit (submission), pi. 
178. Skinner, op cit (submission), pl5. 
179. Skinner, op cit (oral evidence), p660. 
180. Skinner, op cit (submission), pl5. 
181. ibid, pl6. 
182. Skinner, op cit (oral evidence), p660. 
183. id. 
184. id. The NSW Ombudsman has pointed out that tear-resistant blankets exist and are officially standard issue 
for NSW police lock-ups — but in practice many old blankets are still in circulation. One was used by Angus Rigg,
 a juvenile offender who hanged himself in police custody in July 1991. Landa, op cit, ppl07-lll. 
185. Skinner, op cit (oral evidence), p669. 
186. id. 
187. id. 
188. Skinner, op cit (submission), plO. 

Human Rights and Equal Opportunity Commission Page 811 

189. ibid, p9. 
190. id. 
191. Skinner, op cit (oral evidence), p661. 
192. ibid, p662. 
193. ibid, p661. 
194. Skinner, op cit (submission), pl5. 
195. id. The issue of women inmates being moved to male prisons has arisen this year in Victoria, where the 
Government proposes to close down the main women's prison, Fairlea. At Fairlea the women have been living in 
shared cottages where they can cook and spend substantial amounts of time with their children. Local women's 
services operate programs at the prison. The planned closure would see the women moved to Pentridge, a male
 prison where conditions are much more restrictive. Shelley Burchfield, 'Fairlea closure', Framed No22, Aug 1993, p7. 
196. Watson, op cit, pl528. 
197. Walker, op cit, p22. 
198. The jurisdiction with the highest proportion of black prisoners is the Northern Territory, where they make 
up 70 percent of inmates. But based on their share of the general population, the disproportion is worst in 
Western Australia, where Aboriginal people are in prison at 29 times the average. In South Australia the ratio
 is 23.6. In the Northern Territory the over-representation is by a factor of 11; but the Territory also imprisons non-
Aboriginal Australians far more than elsewhere. Walker, op cit, p23. 
199. McDonald, op cit, p2. Over-representation rates in police lock-ups also vary widely. The worst are in
Western Australia (where Aboriginal people are over-represented by a factor of 52), South Australia (a factor
 of 21) and NSW (a factor of 16). In the Northern Territory, 80 percent of people taken into police cells are
 Aboriginal or Torres Strait Islander — an over-representation by a factor of 14. 
200. Carol Kendall, LINK-Up. Oral evidence, Sydney 21.6.91, p593. 
201. See Chapter 23 for a more general discussion of Aboriginal people and mental illness. 
202. Trevor Cox, senior psychologist, NT Department of Health and Community Services. Oral evidence, Alice 
Springs 23.7.92, p201. 
203. Name withheld. Oral evidence, Brisbane 14.8.91, pl458. 
204. John Lawrence, North Australian Aboriginal Legal Aid Service. Oral evidence, Darwin 21.7.92, p94-5. 
205. ibid, pp95-6. 
206. Watson, op cit, pl515. 
207. Claudette Elaro, 'A prison within a prison', Speakout (Newsletter of the Immigrant Women's Speakout
 Association of NSW), June 1992, p4. 
208. Marie Gibson, Coordinator, Migrant Resource Centre. Oral evidence, Townsville 12.8.91, pll45. 
209. id. 
210. Thompson, op cit, p2. 
211. Jolly, op cit, p650. 
212. Lawrence, op cit, pl745; Geary, op cit, p292; Leach, op cit (oral evidence), p55. 
213. Standard Minimum Rule 49(1), cited by Jolly, op cit, p649. 

Page 812 Mental Illness Inquiry 

214. Thompson, op cit, p3. 
215. PMS Review, p55. 
216. The PMS Review Committee described theprisoners as 'grossly inadequate', ibid, p56. 
217. Skinner, op cit (oral evidence), p668. 
218. Jolly, op cit, p650. 
219. Andrews, op cit, pi 132. 
220. Leach, op cit (submission), p2. 
221. Geary, op cit, p292. 
222. Middleton, op cit, pl355. 
223. id. Also Skinner, op cit (submission), p4. number of psychiatric hours available to 
224. Cheryl Kneebone, Schizophrenia Fellowship, Albany. Submission. 
225. Andrews, op cit, pi 127; Dahl, op cit, p405: 'There is still considerable confusion as to what is 
mental illness and what is intellectual disability and what is difficult behaviour.' 
226. Skinner, op cit (oral evidence) p668. See also Hodgson, op cit, pl9. 
227. Wells, op cit (submission), ppl-3. Also Hodgson, op cit, pl7, observing that Queensland police — 
especially the younger ones — are 'on the whole...most co-operative and sympathetic in handling involuntary admission'. 
228. Wells, op cit (oral evidence), p595. 
229. Jolly, op cit, p650. 
230. ibid, p654. 
231. ibid, p648. 
232. Name withheld, op cit endnote 58, pl299. 
233. Dahl, op cit, p405. 
234. PMS Review, op cit, p57. 
235. Prisoners quoted in ibid, pl36-139. 
236. Jolly, op cit, p650. 
237. id. 
238. Walker, op cit, pl3. 
239. Jolly, op cit, p651. 
240. ibid, p650. 
241. Leach, op cit (oral evidence), p55. 
242. Standard Minimum Rules 58 and 59, cited by Jolly, op cit, p649. 
243. Jolly, op cit, p649. 
244. Skinner, op cit (oral evidence), p671. 
245. ibid, p672. 
246. ibid, p671. 
247. Leach, op cit (oral evidence), p56. 
248. Barr, op cit, p422. 
249. Jolly, op cit, p653. 
250. Barr, op cit, pp421-2. 

Human Rights and Equal Opportunity Commission Page 813 

251. ibid, p421. 
252. Leach, op cit (oral evidence), p50. 
253. id. 
254. Tony Calabro, Epistle Post Release Service. Oral evidence, Melbourne 8.4.91, pl54. 
255. Leach, op cit (oral evidence), p50. 
256. Calabro, op cit pl46. 
257. Barr, op cit, p422; Jolly, op cit, p24; Leach, op cit (oral evidence), p51. 
258. id. 
259. Lancefield, op cit, pl54. 
260. Leach, op cit (oral evidence), p52. 
261. id. 
262. ibid, p51. 
263. Barr, op cit, p422. 
264. Lancefield, op cit, pl48. 
265. Sue Marlin, Probation and Parole Officers' Association of NSW. Submission, pi. Similar evidence was 
given by Barr, op cit, p422. 
266. Marlin, op cit, p2. 
267. Lancefield and Calabro, op cit, ppl53-4. 
268. Mels, op cit, pl22. 
269. ibid, ppl22-124. 
270. Ellard, opcit, p61. 
271. Calabro, op cit, pl47. 
272. Milton, op cit, p684. The Victorian Parliament's Social Development Committee has also challenged the
 assumption that psychiatry has expertise in predicting dangerous behaviour. See Parliament of Victoria, 
Social Development Committee, Third Report upon the Inquiry into Mental Disturbance and Community Safety: 
Response to the Draft Community Protection (Violent Offenders) Bill, April 1992, p83. 
273. Neil Rees, president, Victorian Mental Health Review Board. Oral evidence, Melbourne 8.4.91, p25. 
274. ibid, p26. 
275. Leach, op cit (submission), pi. 
276. eg Leach, op cit; Jolly, op cit; Skinner, op cit; Marlin, op cit. 
277. Skinner, op cit (oral evidence), p671. 
278. Barr, op cit, p425. 
279. id. 
280. Middleton, op cit, pl372. 
281. Ben-Tovin, op cit, pp219-220. 
282. Ben-Tovin, op cit, p224. 
283. Clodagh Jones and Marie Sykes, prison visitors, Risdon Prison, Tasmania. Submission. 
284. 'The notorious ward 21 — thank goodness it has finally closed.' Prof Rodney Morice, Director,
 Division of Mental Health Services, Hunter Area Health Service. Oral evidence' Newcastle 9.7.91, p27. 

Page 814 Mental Illness Inquiry 

285. Campbell, op cit, pl94. 
286. Ben-Tovin, op cit, p219. About 7 percent of admissions to Hillcrest are forensic: Anne Burgess,
 Mental Health Unit, South Australian Health Commission. Oral evidence, 
22.10.91, p216. 
287. ibid, p228. 
288. ibid, p219. 
289. Skinner, op cit (oral evidence), p36; Ridley, op cit, pl40. 
290. Ridley, op cit, pi40. 
291. Orme Hodgson, Schizophrenia Fellowship of South Queensland. Oral evidence, Brisbane 14.8.91, pl625. 
Also Shirley Maher, carer, Queensland. Submission, p2. 
292. Mels, op cit, pl22. 
293. Dr Bill Tyler, NT Association for Mental Health. Oral evidence, Darwin 21.7.92, p22. A community group 
in Townsville also expressed concern about an apparently similar facility proposed for Townsville General Hospital.
 However, their main objection was to the 'institutional' character of the plan, rather than the inclusion of
 forensic patients. Name withheld. Oral evidence, Townsville 12.8.91, pl218. 
294. Tyler, op cit, p21. 
295. Ridley, op cit, pl40. 
296. Carol Beaver, manager, Darwin Urban Mental Health Service. Oral evidence, Darwin 21.7.92, pll8. 
297. Mels, op cit, pl23. Also Beaver, op cit, pi 18; Ridley, op cit, pl40. 
298. Barr, op cit, p424. 
299. The definition of insanity or mental illness for the purposes of the criminal law defence is quite 
different from that used for involuntary detention in hospital under civil legislation. 
300. Campbell, op cit, pl86 (citing various judicial decisions). 
301. Rees, op cit, p26. 
302. Barr, op cit, p424. 
303. Pargiter, op cit, pl48. 
304. except in the Northern Territory, where no such body exists. 
305. Mental Health Act Implementation Monitoring Committee, op cit, p31. 
306. Pargiter, op cit, pi48, citing ss76(4) and 68 of the Mental Health Act. 
307. Rees, op cit, p26. 
308. Dr Ian Campbell, Senior Lecturer in Law, University of Western Australia. Oral evidence, Perth 11.2.91, pll9. 
309. id. 
310. Rees, op cit, p26. 
311. id. 
312. Mental Health Act Implementation Monitoring Committee, op cit, p31. 
313. id. 
314. Rees, op cit, p26; Milton, op cit, p690. 
315. Pargiter, op cit, pl55. 
316. Rees, op cit, p26. 

Human Rights and Equal Opportunity Commission Page 815 

317. Milton, op cit, p690. 
318. Mental Health Act Implementation Monitoring Committee, op cit, p33. 
319. The psychiatrist, Dr Russell Pargiter, resigned after the Attorney General rejected the Tribunal's 
unanimous recommendation for the release of Rory Jack Thompson, who had been acquitted of murder by reason 
of insanity. The Tribunal found that the prisoner no longer posed a danger to the public. The Attorney General
 claimed his decision was not political, but based on certain information in his possession. However, he refused
 to reveal what this information was. Michael Lester, 'Rory Jack freedom bid halted', Mercury 31 Jan 1991; 
Dr Russell Pargiter, Submission. 
320. Campbell, op cit (oral evidence), pi 18, citing South Australia v O'Shea (1987) 73 ALR 1. 
321. ibid, pi 19. 
322. ibid, pl20. 
323. X v United Kingdom, European Human Rights Court, 5 November 1981, Series A, No46 p20 para43. 
The court found the UK legislation breached Article 5(4) of the European Convention for the Protection
 of Human Rights and Fundamental Freedoms, which mirrors Article 9(4) of ICCPR. See also the similar 
case of Thynne, Wilson and Gunnell v United Kingdom, (1991) 13 EHRR 101, ppl35-143. 
324. Mental Health Act (UK) 1983, s73. 
325. Campbell, op cit (oral evidence), pl24. 
326. ibid, pl20. 
327. ibid, pl22. 
328. Ashingdane v UK, European Human Rights Court, 28 May 1985, Series A, No93. 
329. R v Home Secretary; Ex parte Herbage [1987] 1 All ER 324. 
330. Milton, op cit, p688. The witness said the lawyers' reluctance to use the defence 'is not because they're 
ignorant — it's because they're informed.' id. 
331. ibid, p691. 
332. ibid, p685. 
333. Rees, op cit, p31; Campbell, op cit (oral evidence), pl25; Mental Health Act Implementation Monitoring
 Committee, op cit, p32; Victorian Sentencing Committee, Sentencing (Volume 2), Attorney General's Department,
 Melbourne 1988, p461; Law Reform Commission of Victoria, Mental Malfunction and Criminal Responsibility 
(Report No.34), 1990, p31; Law Reform Commission of Western Australia, Report on the Criminal Process 
and Persons Suffering from Mental Disorder (Project No.69), 1991, ppll0,116. 
334. Campbell, op cit (oral evidence), pl22; Queensland Government, op cit; Smith, op cit, pp406-7. 
335. e.g. the Victorian Mental Health Act states categorically: ls8(2) A person is not to be considered 
to be mentally ill by reason only...(l) that the person has an antisocial personality.' Cited by Wells, op cit (submission), p5. 
336. W Lucas, 'Forensic psychiatry', in P Beumont and R Hampshire (eds), Textbook of Psychiatry, Blackwell
 Scientific Publications, Melbourne 1989, Chapter 18, p286. 
337. See Chapter 18 for evidence on homeless agency workers, faced with residents behaving in a bizarre
 and threatening manner, being denied assistance from psychiatric hospitals and crisis teams on this basis. 

Page 816 Mental Illness Inquiry 

338. Skinner, op cit (submission), pi; Jones, op cit, p427; Mels, op cit, pl23. 
339. Middleton, op cit, pl372. 
340. Robert Bluglass, 'Current issues in the management of mentally abnormal offenders', Forensic
 Issues in Mental Health, Proceedings of the 12th Annual Congress of the Australian and New Zealand
 Association of Psychiatry, Psychology and Law, 1991, pi8. Also Marlin, op cit, p2; Wells, op cit, p5. 
341. Leach, op cit (oral evidence), p53. 
342. Skinner, op cit (information provided to the Inquiry). 
343. id. 
344. Di Gordon, Australian Association of Social Workers. Submission, p3. 
345. Skinner, op cit (information provided to the Inquiry). Dr Skinner said these patients 
are often also aggressive, manipulative or irritating, which makes hospitals even more reluctant to take them. 
346. Skinner, op cit (submission), pi; Wells, op cit (submission), p5. 
347. Skinner, op cit (information provided to the Inquiry). 
348. Garry David, quoted in Alan Attwood, 'Garry David, and the deeper darkness within', 
Age 14 June 1993. 
349. Hopkins, Disability Services of Central Australia. Quoted in Banks, op cit, attachment 1, p6. 
350. Gordon, op cit, p3. 

Human Rights and Equal Opportunity Commission Page 817 

Part IV 

Other Areas of Concern 

Chapter 26 

MENTAL HEALTH RESEARCH 

If you think medical research is expensive, try disease.1 

Introduction 

It is unfortunately true that by and large those areas which broadly relate to 
community issues and the problems of the relation of medicine and health to the 
community and even areas which relate to disability as distinct from mortality 
have tended not to have been highly regarded by research effort in Australia.2 

The relative paucity of mental health research in Australia places mentally ill 
people at a disadvantage by depriving them of opportunities to lead more 
fulfilling and constructive lives than they can currently enjoy. This constitutes 
an indirect but nevertheless significant form of discrimination.3 

Mental health research is important in a number of areas. These include: 

(a) Providing basic data on the epidemiology of mental illness and mental health 
problems in Australia (taking into account special aspects of Australian society 
such as the status of Aboriginal and Torres Strait Islander peoples; multiculturalism; 
and rural isolation) — thus providing a sound basis for identifying priorities 
for service provision and monitoring their impact. 
(b) Assisting in understanding the aetiology of mental illness and the treatment 
of disorders. 
(c) Evaluating the data derived from (a) and (b) to determine the contribution 
of social factors (including social adversity) to mental illness and mental health 
problems and to develop ways of modifying their impact. 
(d) Conducting health services research, including evaluation research, to 
determine the most effective mental health programs and services and 
effectively monitor and assess the process, impact and outcome of these 
services and programs. 

However, funding for Australian mental health research is poor4 — both in 
absolute terms and in comparison to other OECD countries. No comprehensive 
national data on the prevalence of psychiatric disorder or the availability or 
effectiveness of psychiatric treatments have been developed; the mechanisms 

Human Rights and Equal Opportunity Commission Page 821 

underlying nearly all psychiatric illnesses are yet to be identified; treatments
 are often inadequate or ineffective, objective markers of psychiatric illness (by 
which, for example, treatment might be monitored) are lacking; and the ability to 
predict outcomes for individual patients (eg suicide or chronic disability) is
 still extremely limited. 

At a time of major changes in the provision and administration of psychiatric 
services — with, for example, a changing balance between community and 
institutional care and an increasing role being assumed by the Federal 
Government in the formulation of policies affecting the mentally ill — the 
current limitations in the availability of integrated psychiatric data about the 
prevalence of psychiatric disorder and the scope and efficacy of current 
psychiatric services constitute major impediments to our capacity to plan and 
deliver effective programs.5 If we are to change this situation — and we must 

— it is important to identify the factors which have produced it. 
Some of the most significant elements contributing to the gap between the need 
for and availability of psychiatric research in our country are: 

(a) Funding available for medical research generally in Australia is low by 
international standards. 
(b) It is much more difficult to raise money from the public for research 
into psychiatric disorders than it is to raise it for research into other 
major illnesses such as heart disease, cancer and diseases commonly 
affecting children. 
(c) Few philanthropic organisations target psychiatric illness as a priority 
area for funding (the Australian Youth Foundation and the Rebecca 
Cooper Foundation are notable exceptions). 
(c) The tradition of psychiatric research in Australia is only a relatively 
recent one. (Virtually no significant psychiatric research was undertaken 
until after the Second World War.)6 
(d) The most seriously ill psychiatric patients have, typically, been treated 
in State psychiatric hospitals. These hospitals have not embraced or 
fostered a tradition of research — although this situation has been 
changing in recent years. 
(e) The heavy clinical and administrative demands placed on psychiatrists 
in the public sector significantly impede their capacity to conduct 
research. 
(f) Research into major mental illnesses is often hampered by the fact that 
seriously disturbed patients may not be able to give informed consent to 
participate in (and therefore do not participate in) research studies. 
(g) Psychiatric research is often very complex and unavoidable methodological 
difficulties sometimes disadvantage psychiatric research projects 

Page 822 Mental Illness Inquiry 

in comparison to more basic, science-oriented disciplines in the 
competitive grant process. 

(h) Prior to the recent National Mental Health Policy, there was little 
incentive and even less action taken to create a National Data Set on 
Mental Illness. The diversity of settings in which psychiatric care is 
provided (public psychiatric hospitals, private psychiatric hospitals, 
psychiatric units of general hospitals, community clinics, and general 
practice) represents a significant impediment to establishing standardised 
methodologies to develop such a database — as does the difference in 
the manner in which different States collect their data. 
(i) There is a very large discrepancy between the income a psychiatric 
graduate can earn in research and in private practice. This 'research 
disincentive' contributes to the fact that very few psychiatrists apply for 
Post Doctoral Scholarships or Fellowships within the National Health 
and Medical Research Council (NHMRC).7 
(j) Despite the outstanding efforts of community support groups such as the 
Schizophrenia Fellowships, there is still inadequate recognition given to 
the need to effectively lobby for improved psychiatric research funding 
at the community, professional, bureaucratic and political levels. 
This chapter attempts to analyse these and other obstacles impeding progress 
in mental health research in Australia — with some attention to the organisational 
structure within which psychiatric research is conducted in our country 
(in order to ensure that if much needed funding increases for such research are 
provided following this Inquiry, they can be effectively allocated.)8 

Support for Medical Research in Australia 

The thing that.. .has enabled people with mental illness to become as self-reliant
 as possible has not been legislation, it has been the development of new treatments
 for mental illness.9 

Overall, Australia devotes a relatively small proportion of its GDP and also of 
its total health expenditure to medical research. The recent Independent 
Commission on Health Research for Development recommended the investment 
of at least two per cent of national health expenditure on medical research.10 
The Commission estimated that in 1986 Australia spent only a third of its total 
health expenditure — 0.7 percent — on publicly-funded medical research. In 
fact, of the 20 industrialised countries for which estimates of this percentage 
were made, Australia ranked third to last (ahead of only Spain and Ireland.)11 

Human Rights and Equal Opportunity Commission Page 823 

There are many reasons why medical research expenditure generally should be 
increased, including the following: 

1. Australia has a good track record in biomedical research, despite comparatively poor
 funding — but an increasing percentage of highly recommended 
project applications to the NHMRC are remaining unfunded. This fact, together 
with the relatively poor opportunities for professional advancement within 
medical research organisations (and this applies particularly to psychiatry) 
means that as a country we will find it increasingly difficult to retain the 
researchers of the future. 
2. Australia must continue to increase the number of its medical researchers 
who are in the forefront of the international medical research community — in 
order to improve our capacity to identify and translate the more promising 
medical research results from around the world into methods of improved 
diagnosis and treatment here. It is also important for our medical research 
community to be able to critically assess and reject unpromising leads in order 
to save funds which might otherwise be wasted on the development of 
inappropriate and unsuccessful treatments or technologies. 
3. Improved treatment not only enhances longevity, it saves money. For 
example, in the United States (which spends substantially more than Australia 
on research), the average length of life has increased at an average rate of ten 
weeks per year since 1950. Impressive savings have been made with the 
conquering of important diseases.12 

Because these savings are gradually introduced into the community, they are 
not as apparent to economic planners as more immediate economies. To some 
extent they are offset by the costs associated with increased longevity. The need for 
the community to support people into their old age is, however, a treasured expectation 
— especially as one passes middle-age. 

4. Australia has generated excellent peer-review mechanisms in medical 
research which ensure that funds are used very efficiently. (In fact we have 
been recognised as having one of the best medical research peer review systems 
in the world.)13 

Cost of Mental Illness and Funding for Research 

The greatest curtailment to the rights of the mentally ill is produced by the disease 
itself...14 

Page 824 Mental Illness Inquiry 

Costs of Mental Illness in Australia 

Psychiatric illnesses affect the very core of human existence and result in 
terrible suffering — primarily to patients, but also, and substantially, to families 
and loved ones. 

The quantification of the cost of psychiatric illnesses to the Australian nation 
has not been satisfactorily addressed. In order to produce a 'best estimate' it is 
necessary to approach the task from several different vantage points — to 
determine if a consistent range of estimates is possible. 

In this context, preliminary estimates for the cost of mental illness to Australia 
may be derived from a number of sources: 

(a) The Eisen Wolfenden Report 
The Eisen Wolfenden Report, commissioned by the Commonwealth Department 
of Community Services and Health and published in 1988, estimated that the 
overall cost of psychiatric illnesses to Australia was $2.74 billion per annum.15 

Adjusted by the CPI index this represents $3.53 billion (in 1992 dollar 
terms).16 

(b) Estimate of Total Costs from Direct Care Cost Data 
An assessment of the direct cost of psychiatric care was provided in the 1991 
Report of the Mental Health Task Force of the Australian Health Minister's 
Advisory Council.17 Combining State expenditure on psychiatric services 
($863 million); Commonwealth Medical Rebates on psychiatric consultations 
($116 million); the cost of acute psychiatric care in public hospitals ($450 
million); private hospital care ($126 million)18 and expenditure via the 
Pharmaceutical Benefits Scheme on drugs commonly prescribed in psychiatric 
care ($60 million) results in a total direct care expenditure estimate of $1,615 
billion. Indirect costs of major psychiatric illnesses such as schizophrenia are 
estimated to exceed direct costs by a ratio of 3:1.19 Based on this formula, the 
indirect economic burden would, therefore, be $4,845 billion and the total cost 
$6.46 billion. 

(c) Estimates from the National Foundation for Brain Research, Washington DC, USA 
The Consultancy firm Lewin/ICF recently undertook an economic analysis of 
the cost of disorders of the brain in the United States. They concluded that 
psychiatric illnesses cost that country $US136 billion.20 This represented 2.48 

Human Rights and Equal Opportunity Commission Page 825 

percent of the gross domestic product.21 The gross domestic product for 
Australia in the financial year 1990-91 was $256.9 billion.22 If the treatment 
and consequences of psychiatric disorders incur costs of a similar magnitude 
and a similar percentage of GDP in Australia to the figures calculated for the 
United States, this would represent an approximate cost of $6.36 billion (1992 
Australian dollars). 

The average of these three estimates for the cost of psychiatric illnesses ($3.53, 
$6.36 and $6.46 billion) is $5.45 billion. (It is consistent with the correct figure
 being of this order of magnitude that just one of the many psychiatric disorders 
affecting the Australian community, schizophrenia, is estimated to cost our country 
$1.89 billion per annum.)23 

(d) Estimates from the Australian National Association for Mental Health 
In 1988 the Australian National Association for Mental Health (ANAMH) 
estimated the costs of mental illness to the Australian community at $3 billion 
in direct costs — without including pensions.24 

Funding for Mental Health Research in Australia 

It is difficult to establish precisely how much money is currently being spent 
on mental health research. However, a preliminary estimate suggests that 
approximately $8.2 million was spent in 1992 on identified psychiatric 
research.25 Other funding for such research is provided via the University 
Departments of Psychiatry and via psychiatrically-relevant neuroscience grants 
from the NHMRC. 

When all these funds are combined perhaps $10 million per annum is currently 
being spent on psychiatric and related research in Australia.26 This represents 

0.28 percent of the costs of psychiatric illness to the community, using the most
 conservative global estimate of these costs ($3.53 billion) and 0.18 percent of 
the averaged global costs ($5.45 billion). Perhaps, more significantly, it represents 
less than one per cent (0.62 percent) of the identified direct costs of psychiatric 
care ($1,615 billion). If one applies the recommendation that 2 percent of health
 care costs should be invested in medical research27 specifically to psychiatric 
care costs, then we should be spending at least $32.3 million on psychiatric 
research per annum.28 

Page 826 Mental Illness Inquiry 

Commonwealth Funding Sources 

It is necessary to understand the structure and function of certain key 
Commonwealth medical research funding agencies in order to evaluate ways of 
increasing effective psychiatric research in Australia. 

The National Health and Medical Research Council 

The NHMRC was established in 1937. Its mandate is to improve health, to 
consider matters relating to the improvement of health, the prevention of 
disease, health care, medical care, dental care, health research and medical 
research and ethical issues in relation to health. The 1990 Triennial Review of 
the NHMRC recommended that it become a statutory body — thereby securing 
its independence. Legislation regarding this change has been introduced into 
Parliament. 

The NHMRC's main committees with regard to research are the Medical 
Research Committee (MRC) and the Public Health Research Development 
Committee. The MRC, which is biomedically oriented, allocated $101 million 
in 1992. The Public Health Research Development Committee, which oversees 
population-based research, allocated $4.8 million during the same year. 

Australian Institute of Health and Welfare (AIHW) 

The Australian Institute of Health was established in 1987.29 Its role was 
expanded in May 1992 to include the collection of data relating to community 
welfare. Its functions now are to: 

• collect and assist in the production of health and welfare-related information and 
statistics; 
• conduct and promote research into the health of Australians and their health services; 
• develop statistical standards relevant to health, and to health and welfare services; 
• publish methodological and substantive reports on work carried out by or in association 
with the Institute; 
• undertake studies into the provision and effectiveness of health service and technologies; 
• make recommendations on the prevention and treatment of diseases and the 
improvement and promotion of health and health awareness of the people of Australia. 

Until now, neither the Census nor National Health Surveys have collected much 
data on mental illness.30 However, the Australian Bureau of Statistics (ABS) 
has approached the Australian Society for Psychiatric Research to improve the 
quantity and quality of the mental health data which it is collecting.31 

Obstacles to the systematic and comprehensive collection of national mental 
health data include: 

Human Rights and Equal Opportunity Commission Page 827 

• The difficulty in defining what constitutes mental health and psychiatric 
illness. 
• The fact that psychiatric hospitals do not contribute to the hospital 
morbidity data base compiled by AIHW. (The Institute does receive data 
from psychiatric units within general hospitals.) 
• The variation in the quality of data from each State. 
• Financial constraints. (In order to collect a uniform data set on mental 
health, the States will need to adjust and augment their data collection 
systems — in some cases in a substantial and costly manner.) 
• Concerns about confidentiality — which is an important issue when one 
considers the stigma suffered by people with mental illness. (See 
Chapter 9 — Community Care and Treatment.) 
Health, Housing, Local Government and Community Services 
Research and Development Grants 

The Commonwealth Department of Health, Housing, Local Government and 
Community Services32 offers Research and Development Grants aimed at 
improving the administration, planning and delivery of health and community 
care within Australia. This program, which does not fund either biomedical 
research or clinical trials, focusses on: 

• medical technologies 
• economic and health status impact; 
• financing and utilisation of services; 
• preventive health services; 
• housing services including crisis and special services; 
• research into services for people with disabilities; 
• research into rehabilitation services; 
• research into services for children and for aged persons; 
• examination of economic issues including health, housing and 
community care, financing and utilisation. 

In 1992, 17 mental health projects totalling $601,949 were funded via the 
Research and Development Grants Scheme (which had a total funding base of 
$1.8 million.)33 

Page 828 Mental Illness Inquiry 

The NHMRC and Mental Health Research 

Experts providing information to the Inquiry indicated several cogent reasons 
why an augmented psychiatric research effort should remain under the umbrella 
of the National Health and Medical Research Council. The principal reason 
advanced was that the NHMRC provides a proven and effective infrastructure 
within which research grants can be thoroughly assessed. To develop and 
maintain a similar system separate from the NHMRC would be both expensive 
and difficult. 

A second reason for ensuring that the NHMRC remains the auspicing 
organisation for the majority of psychiatric research is that such an arrangement
 ensures psychiatric researchers are part of an integrated and mutually supportive
 community of medical researchers. Such collegiality is of considerable importance
 when research projects with cross-disciplinary input are 
involved. 

The Performance of Research in Psychiatry and Psychology in NHMRC Project Grants 

The precise proportion of NHMRC funds allocated to psychiatry, psychology 
and related areas of research is unclear.34 According to an analysis by discipline 
in 1989, psychiatry and psychology received only 2.6 percent of all NHMRC funds, 
whereas according to clinical categories, 10.1 percent of project funding
 was allocated to mental health and neurosciences. 

While 2.6 percent is clearly an underestimate (because a number of neuroscience 
research projects have significant relevance to psychiatric disorders), 
the figure of 10.1 percent is clearly an overestimate (because in the neurosciences 
Australia is particularly strong in areas such as vision, autonomic nervous system 
and neurotoxicological research and most of this is unlikely to have much relevance 
to psychiatry.) The precise figure is therefore somewhere between these two figures 
— but probably closer to the lower one. 

A number of reasons have been advanced to explain this relatively poor success 
rate of psychiatric grant applications within the NHMRC framework.35 They 
include the fact that it is difficult for clinical disciplines such as psychiatry
 to compete with those disciplines which have large basic science components and 
which rely on the use of animal experimentation or cell cultures and technically 
sophisticated methodologies. Researchers from such disciplines have a greater 
capacity to design experiments which are comparatively free of confounding variables
 and which address fundamental mechanisms or aetiologies of disease in comparison 
to clinical studies, especially in psychiatry, where issues such as 

Human Rights and Equal Opportunity Commission Page 829 

previous medication, problems with informed consent, use of recreational 
drugs, variable nutritional status and secondary psychological problems make 
the task of the researcher much more difficult.36 

In addition, intensive psychiatric research has been much slower to develop and 
there is not the tradition of psychiatrists doing full time research in Australia.
 (There are, at most, four full-time psychiatric researchers in Australia at present.) 

Affirmative Action in Medical Research 

So I would want an increased emphasis given to the social aspects of psychiatry, 
the epidemiology of mental illness and, in particular,... such matters as... social
 inequality and the mechanisms by which the quality of life of people with a mental
 illness is affected by the immediate social and physical environment... they're 
placed in.37 

It is obvious from the evidence considered by the Inquiry that proper respect 
for and protection of the human rights of Australians affected by mental illness 
requires urgent affirmative action in relation to redressing the gross imbalance 
inherent in the funds currently allocated to mental health research. 

Just as modern economic commentators recognise that the approach to 
economic planning can be neither purely Keynesian nor Friedmanite, so too the 
approach to research funding must be a judicious admixture of selection — 
based on a combination of identified research priorities reflecting human rights 
considerations and health needs within the Australian community and on 
scientific excellence.38 

Affirmative Action in the USA: The National Institute of Mental Health 

The amount of federal funding for psychiatric research in the United States is 
vastly greater than in Australia — on both absolute (a ratio of 238:1) and per 
capita (14:1) bases. (The population of the US is 15 times greater than 
Australia's.) In 1989 the NHMRC allocated $2.4 million to psychiatric research 
and the US National Institute of Mental Health allocated $A570 million. Yet 
even in the United States there is a recognition that funding for psychiatric 
research is far below the levels warranted by the impact of mental illness on 
the community. 

The administrative structures for mental health research funding in the US have 
changed numerous times. The National Institute of Mental Health (NIMH) was 
originally established as part of the National Institutes of Health (NIH — the 
NHMRC equivalent), became independent in 1968, and rejoined the NIH in 

Page 830 Mental Illness Inquiry 

October 1992. It is therefore informative to consider the development of NIMH 
in the context of considering whether the distribution of Australian federal 
mental health research funding should remain the general responsibility of the 
NHMRC, or whether a separate organisation or specified subdivision of the 
NHMRC should undertake this task. 

Just as the Commonwealth AIDS research grants were established because of 
a particular series of events — specifically the growing prevalence of AIDS in 
the community and greater public awareness of the tragedy of this disease — 
the National Institute of Mental Health was established following the forced 
recognition of the prevalence of mental illness in the community: a recognition 
which occurred as a result of the Second World War.39 

The NIMH was established in 1946 under the National Mental Health Act in 
an effort to foster 'research, investigations, experiments and demonstrations 
relating to the cause, diagnosis and treatment of psychiatric disorders'. It was 
hoped that the establishment of the Institute as one of the National Institutes of 
Health would coordinate and strengthen the disparate psychiatric research 
efforts around the country. 

By 1952 the NIMH research budget had grown to $5 million. A decision to 
transfer NIMH away from NIH in 1968 occurred when NIMH added to its 
responsibilities the considerable service function associated with the Community 
Mental Health Centres program which was introduced during the Johnston 
administration. When the National Institute of Drug Abuse (NIDA) and the 
National Institute on Alcohol Abuse and Alcoholism (NIAAA) were created in 
1973, the administration of the three Institutes (ie including NIMH) was placed 
in the hands of the newly formed Alcohol, Drug Abuse and Mental Health 
Administration (ADAMHA). 

The move to separate NIMH from NIH and place it under the administration 
of ADAMHA was considered by its supporters to have enabled much stronger 
advocacy on the part of mental health research and protected non-biological 
psychiatric research, in particular, from being cut. (As mentioned above, the 
Institute returned to NIH in 1992.) These factors have some relevance to the 
current situation in Australia. 

A recent review which summarised the latest data on federal support for mental 
health research in the United States40 found that in 1988 US health research 
received funding of $18.7 billion (which represented 14.8 percent of total US 
research and development). In the same year, mental health and substance 
abuse research received only 4.7 percent of this budget — although the costs 

Human Rights and Equal Opportunity Commission Page 831 

of mental health and substance abuse were estimated to be 12 percent of total 
US health costs. 

Put another way, approximately 1.3 percent of [the direct costs of] mental health 
and substance abuse are invested by society in research on these disorders compared 
with society's investment of 3.4 percent of overall health costs of general 
biomedical research.41 

The equivalent figure for Australia is that 0.62 percent of the costs of mental 
health are invested in psychiatric research. 

Affirmative Action in Australia 

Affirmative Action within the Medical Research Council of the NHMRC 

Funding allocation within the NHMRC is primarily determined on the basis of 
scientific excellence. The NHMRC has, however, also supported research in 
a number of relatively undeveloped but particularly deserving areas.42 

One important form of support is the Special Initiative Grant.The threshold for 
these grants is slightly lower than for grants within the remainder of the project
 grant system.43 In 1992, designated special initiative areas were: Aboriginal health;
 alcohol and substance abuse; asthma; breast and prostate cancer; dentistry and dental
 services; menopausal health; environmental health and commercialisation. 

The designation of special initiative areas is reviewed on a yearly basis.
 Mental health was a special initiative area for a number of years because of 
its low success rate, but was not included in 1992 because its success rate had 
improved in 1991. 

The second mechanism by which the NHMRC provides support for deserving 
clinical research is through the creation of Special Units.44 Two of the 
NHMRC's five special units are conducting psychiatric research — the 
NHMRC Social Psychiatry Research Unit and NHMRC Schizophrenia Research 
Unit. 

The Network of Brain Research into Mental Disorders 

In the August 1992 Commonwealth Budget, provision was made for the 
establishment of a network of 'Brain Research into Mental Disorders'. $5 
million was allocated over six years.45 It is anticipated that several centres 
around Australia will join the network and form discipline-based consortia (eg 

Page 832 Mental Illness Inquiry 

neuroimaging, neurochemistry or molecular biology consortia) and disorder-
based consortia (eg schizophrenia, mood disorders and Alzheimer's disease 
consortia). 

One compelling reason why neuroscientific research in psychiatry should be 
even more strongly encouraged is that in recent years the technical advances in 
the neurosciences have been extraordinarily swift and revealing. These advances 
have laid the foundations for quite specific research which could not even have 
been contemplated ten years ago. 

Commonwealth Aids Research Grants — An Analogy 

Commonwealth Aids Research Grants (CARG) are distributed by the AIDS 
section of the Commonwealth Department of Health, Housing, Local 
Government and Community Services. The CARG scheme supports Investigator-
Initiated Project Grants, Scholarship and Postgraduate Research 
Programs and three national centres — the National Centres in HIV Social 
Research, HIV Virology Research and HIV Epidemiology and Clinical 
Research. 

Theoretically, it should have been possible for the augmentation in AIDS 
research to occur via established NHMRC mechanisms. One of the reasons that 
this did not occur was, perhaps, that AIDS was considered to represent a 
community crisis and that the established mechanisms might have been too 
inflexible and unresponsive to ensure a major boost to AIDS research within 
Australia. In contrast, psychiatric illnesses are not seen by many to be a 
community crisis (perhaps, in part, because they have always been a feature of 
our society), although the number of patients with psychiatric disorders and the 
consequences these disorders have on their lives, the lives of their families and of 
the community at large, make these illnesses the most neglected crisis of our times. 

To illustrate the conversion of public awareness into constructive action with 
regards to HIV research, since the creation of CARG, funding for AIDS 
research in Australia, since the creation of CARG, has increased from a base 
of $1.4 million in 1986 when CARG began, to $10.6 million in 1992. 

Some Specific Issues in Mental Health Research 

The Performance of Mental Health Researchers in Australia 

Notwithstanding the meagre resources allocated to psychiatric research, 
Australian researchers are well respected internationally.46 

Human Rights and Equal Opportunity Commission Page 833 

Indeed, the extent to which Australian psychiatric research can make a 
difference is illustrated by the work of John Cade — an Australian pioneer in 
the discovery of lithium for the treatment of manic depression.47 The introduction of
 lithium into psychiatric practice worldwide has not only improved the quality of life
 for many thousands of individuals, it has also substantially reduced the cost of care
 for people with manic depression and provided substantial economic gains flowing from
 increases in productivity — by 
returning to the workforce many sufferers who had either been unable to 
contribute at all because of their illness, or only able to do so in a significantly 
impaired manner. It has been calculated that between 1969 and 1979 an estimated 
$US4 billion was saved in the US alone as a result of lithium's 
introduction into psychiatric practice.48 

Cade's discovery illustrates the importance of linking clinical and basic research 
and highlights the fact that the prevalence and expense of psychiatric services 
makes major discoveries — even though they do not occur with either 
regularity, frequency or predictability — extremely worthwhile. The savings 
accruing from such discoveries massively outweigh the cost of investing in 
productive, marginally productive, and, inevitably, some unproductive 
psychiatric research. 

Training Researchers 

Evidence presented to the Inquiry on the general training needs of mental health 
professionals is discussed in Chapter 6 of this report. In the specialised field 
of psychiatric research it is clear that much more needs to be done to attract 
psychiatrists and psychologists into career paths which will lead them to 
undertake substantial, if not full-time, research activities once they have 
completed their primary postgraduate qualifications. 

One of the main mechanisms used by the NHMRC to encourage young 
investigators to pursue a medical research career is its Training Fellowship 
Scheme. Psychiatrists, however, rarely enter the scheme. A review of the 
period 1979-8349 revealed that during those years only one out of seventy-six 
fellows was a psychiatrist.50 

State governments are also pursuing training initiatives. Examples include the 
fellowships offered by the NSW Institute of Psychiatry and special research 
scholarships in Queensland. Professional organisations such as the Royal 
Australian and New Zealand College of Psychiatrists and the Australian Society 
for Psychiatric Research also support and encourage research training. 

Page 834 Mental Illness Inquiry 

State Government Supported Mental Health Research 

State government contributions may be direct (through the mental health 
divisions of government departments, or the research arms of government 
health departments) or indirect (through Health Promotion Foundations, such 
as those operating in Western Australia and Victoria.) The Victorian Health 
Promotion Foundation, for example, has provided substantial funding for 
research into schizophrenia, the mental health problems of youth and the 
elderly, and the impact on carers.51 

Notwithstanding efforts currently under way in NSW52 and Western Australia, 
two State governments are noteworthy for their support of psychiatric research 
— Victoria53 and Queensland. The Victorian Government set up the Mental 
Health Research Institute of Victoria in 1956, as part of the State Health 
Department. It conducted important epidemiological and health service 
evaluation work from its establishment until the early 1980s — but was 
hamstrung by a relatively poor budget, the absence of laboratory facilities and 
the fact that it was part of a Government bureaucracy. A major change 
occurred in 1987. The Institute was made independent, given its own Board of 
Management and, increasingly, a more appropriate budget. Members of the 
Inquiry inspected the Institute, which is now based at Royal Park Hospital and 
has a staff of 55. Its expenditure in the financial year 1991-92 was $2.0 
million. 

The recently established Early Psychosis unit at Parkville in Melbourne is also 
undertaking pioneering research work (see Chapter 20 on Children and 
Adolescents.) 

The NHMRC Schizophrenia Research Unit, which operates in Melbourne under 
the auspices of the Mental Health Research Institute, consists of a number of 
laboratories and specialist units including the Neuropathology, Neurochemistry 
and Neuroendocrinology Laboratories and the Psychopharmacology, Genetics 
and Biostatistics Units.54 

Queensland also has a very progressive and productive psychiatric research unit 
which is primarily funded by the State Government. The Wolston Park Hospital 
Clinical Studies Unit, also inspected by the Inquiry, was established in 1988. 
Its activities centre on a 22 bed inpatient unit and associated Clinical Electrophysiology 
Unit at Wolston Park Hospital and laboratories in the Department of Medicine at 
Princess Alexandra Hospital. 

The Unit consists of 40 permanent staff who are members of a number of 
teams, including the Social Psychiatry and Epidemiology, Psychopharmacology, 

Human Rights and Equal Opportunity Commission Page 835 

Phenomenology and Treatment, and Genetics Groups. The clinical focus of the 
unit is schizophrenia and its funding for 1991-92 was approximately $1 
million.55 

There is close co-operation between the Clinical Studies Unit and the Mental 
Health Research Institute of Victoria. Both groups have also developed strong 
international links. The Clinical Studies Unit has made excellent progress in the brief
 period since its establishment and the Queensland Government has 
demonstrated a welcome commitment to encouraging research into serious 
mental disorder.56 

An excellent model for State-supported research facilities exists in the United 
States, where the main responsibility for psychiatric care is also at the State 
level and many States have undertaken considerable responsibility for 
psychiatric research. Despite the comparatively healthy investment in such 
research by their Federal Government, it is widely recognised in the United 
States that substantial State contributions are needed to augment Federal 
Government allocations. Thus, the median annual State contribution to 26 
psychiatric research Institutes is $US6 million.57 Twenty of the 26 institutes 
receive at least $1 million and seven receive at least $10 million. (The median 
staffing level of these psychiatric institutes is 152.) 

Contributions Made by Professional Groups and Organisations 

As mentioned previously, both the Australian Society of Psychiatric Research 
and the Royal Australian and New Zealand College of Psychiatrists are 
prominent in the research field. In addition to the provision of research 
programs, the College has developed a research register, gives small grants-in aid and conducts
 training programs. 

Psychologists conduct a great deal of research which is relevant to psychiatry 
and psychiatric treatments. Psychiatric nurses are also becoming increasingly 
involved in mental health nursing research. The Australian College of Mental 
Health Nurses promotes research and a Centre for Mental Health Nursing 
Research has been established at the Queensland University of Technology. 

Contributions by Consumer Support Groups 

Several of the larger consumer support organisations, such as the Schizophrenia 
Fellowships or the Mental Health Associations, are actively seeking to promote 
psychiatric research and are seeking funding. In NSW, for example, the Schizophrenia Fellowship has 
initiated the Neuroscience Institute of Schizophrenia and Allied Disorders (NISAD). 

Page 836 Mental Illness Inquiry 

The Need for Further Research into Community Based Programs 

It is clear from the evidence that research is also needed into the practical 
workings of psychiatric treatment, rehabilitation and care services. (In essence, this is a matter of
 evaluating what works, what does not work and why.) 

The Inquiry received extensive evidence from consumers concerning the apparent 
effectiveness of some residential, day and outreach support services for 
people affected by mental illness. There is clearly a desperate need for more 
such services — which can only be met if there is a substantial allocation of 
funding. 

The Inquiry recognises, however, that policy makers must have research evidence 
to back up the experience of service providers. More effort therefore 
needs to be devoted to identifying factors that contribute to successful outcomes for people with mental
 illness who are utilising non-clinical care and support services. More difficult, but equally important, 
will be studies that seek to determine the comparative effectiveness of day and residential programs;
 of accommodation services that are permanently staffed against those where staff 
are on-call; and of residential services and outreach support services. 

Research in the Context of the National Mental Health Policy 

The recently created Mental Health Section of the Department of Health, 
Housing, Local Government and Community Services has the mandate for 
overseeing implementation of the National Mental Health Policy. The relevant 
unit was established in 1991 and is currently a small section with a staff of only five people. 
It will continue to play a major role in determining the manner in which additional funds 
allocated are spent and in negotiating an agreement with the States with regard to the program. 

As funding responsibilities for psychiatric research shift away from the States 
to the Commonwealth, it is particularly important that any of the psychiatric 
research funding provided by the States (especially Victoria and Queensland) 
is either maintained by the States or, alternatively, an appropriate arrangement 
is made between Commonwealth and State governments to ensure that the 
Commonwealth assumes responsibility for continuing the funding which is 
enabling this valuable psychiatric research to be conducted in a manner which 
would not be possible if the sole funding source was the NHMRC. 

Just as Pinel struck the chains from his patients in the late 18th century, the best care...
 for people with mental illnesses and in turn the best way of improving their human rights is to
 improve the treatment... so that they are not imprisoned by their illnesses.58 

Human Rights and Equal Opportunity Commission Page 837 

1. W Gibson, 'The Cost Of Not Doing Medical Research', Journal of the American Medical Association,
 v244, 1980, pp 1817-1819. 
2. Prof I Webster, Professor of Community Medicine, University of NSW. Oral evidence, Sydney 20.6.91, p466. 
3. See Chapter 2 - Relevant Human Rights Provisions, particularly the commentary on the Declaration on 
the Rights of Disabled Persons — which recognises that people with disabilities, including psychiatric 
disabilities, are entitled to: 'any necessary treatment, rehabilitation, education, training and other 
services to develop their skills and capabilities to the maximum' (Principle 6). 
4. Some witnesses to the Inquiry have described the state of research funding as 'parlous' — see, for
 example, Dr D Leonard, Director Clinical Services, Royal Park Hospital and Dr M Duke, representing 
the Victorian Branch of the RANZCP. Oral evidence, Melbourne 14.4.91, p342. 
5. Report of the Mental Health Taskforce to the Overarching Committee on Health and Aged Care and to 
the Australian Health Ministers' Advisory Council, AGPS, Canberra, 1991. 
In its report the Mental Health Taskforce to the Australian Health Ministers' Advisory Council 
highlighted the fact that mental health research has traditionally had a low priority in gaining access 
to research resources and indicated the following seven priorities in the area of mental health research
 and evaluation: (a) development of a national mental health data strategy; 
(b) regular reviews of outcomes of services provided to the seriously mentally ill; (c) development of
 effective clinical information systems to enable improved planning and evaluation; (d) increased 
promotion of basic and applied mental health research and its application in prevention and 
intervention programs; (e) affiliation of appropriate staff between Universities and Health Departments; 
(f) development of programs to focus specifically on promoting research skills in mental health; 
(g) establishment of a comprehensive suicide research and prevention program. 
6. Whereas fields such as immunology and cardiovascular research have had the benefit of large and 
dynamic research institutions, such as the Walter and Eliza Hall and Baker Institutes, little funding 
has been provided to develop similar institutional structures in psychiatric research. Recent 
developments at the Mental Health Research Institute of Victoria, the Clinical Studies Unit at 
Wolston Park Hospital in Brisbane, and the NHMRC Schizophrenia and Social Psychiatry Units point to
 a growing recognition that such structures are essential to the furtherance of the goals of 
psychiatric research. Sciences associated with psychiatry have recently made major conceptual
and technical advances. Prior to this, the discipline emphasised a broad-ranging collection of empirical
 data in what was known as the 'pre-theoretical phase', rather than focussing on solid data-based theoretical
 frameworks. The combination of this fact, and a lack of convincing animal models of psychiatric 
illness, may have acted as a disincentive to potential researchers seeking a more secure structure 
within which to develop their research plans. 

7. While some organisations such as the NSW Institute of Psychiatry have been providing better funded
 research fellowships, the point must be made that without a solid training base the future of 
psychiatric research is very limited. 
8. Medical research in Australia is internationally competitive, when considered in relation to
 the tight budgetary constraints which operate to limit its expansion and development. An independent
 review of Australian research, including medical research, was undertaken by the Australian Science 
and Technology Council (ASTEC) in 1989. In its report Page 838 Mental Illness Inquiry (ASTEC, Profile
 of Australian Science, Canberra, 1989) ASTEC stated that clinical and biomedical research in Australia 
'has never been in a stronger position in international terms' especially in the specific areas of 
cardiovascular research, neuroscience, immunology, cellular and molecular biology, vision research
 and comparative physiology. It noted, however, a worrying trend, in which medically qualified 
graduates were moving away from medical research. It highlighted the need to provide incentives 
and encouragement to bring them back. It also noted Australia's weakness in a number of areas of
 medical research and the particularly low funding levels allocated to certain areas which had a 
major impact on morbidity and on quality 
of life. 

9. Dr David Copolov, Director, Mental Health Research Institute of Victoria. Oral evidence, 
Melbourne 8.4.91, p67. 
10. Independent Commission on Health Research for Development, Essential Link to Equity and
 Development, Oxford University Press, 1990. 
11. id. Of the 23 countries for which publicly funded medical research was calculated as a percentage 
of GDP, Australia outranked only Spain, Ireland and Greece. 
12. In this regard, note should be taken of the subsequent section of this chapter on the Performance
 of Psychiatric Researchers in Australia for the savings accruing from the discovery of lithium's 
anti-manic properties. 
13. R Smith, 'Science in Australia: Alive, Well, Kicking, and Growing,' British Medical Journal,
 v302, 1991, pp946-948. 
14. Leonard and Duke, op cit. 
15. P Eisen and K Wolfenden, The National Mental Health Services Policy: Report of the Consultancy 
to Advise Commonwealth, State and Territory Health Ministers, Department of Community Services and
 Health, Australian Government Publishing Service, Canberra, 1988. 
16. The Australian Bureau of Statistics (ABS) states that the CPI for June 1987 for major capital
 cities was 82.6 and the CPI for June 1992 was 107.3; this represents a 29 percent increase in the 
CPI between 1987 and 1992. $2.74 billion increased by 29 percent is $3.53 billion. 
17. Report of Mental Health Taskforce, op cit, pl8. 
18. It is difficult to obtain precise costings on private psychiatric hospital care in Australia.
 This estimate was made using the following assumptions:- During the financial year 1991/2 there
 were 4,700 private psychiatric admissions in Victoria. Extrapolating to the rest of Australia 
(Victoria represents 25.1 percent of the Australian population) this would mean 18,725 private
 psychiatric admissions per annum. For an estimated admission length of 21 days at $350/day - 
the total cost would be $138 million. 
19. G Andrews, W Hall, G Goldstein et al, 'The Economic Costs of Schizophrenia', Archives of 
General Psychiatry, 1985, v42, pp537-538. Professor Andrews is Professor of Psychiatry and 
Director of the Health Services Research Group, Clinical Research Unit for Anxiety Disorders, 
University of NSW at St Vincent's Hospital. 
20. Editorial, Nature, v357, 1992, p348. 
21. The estimate for the total cost of neurological and psychiatric disorders as well as drug
 and alcohol abuse was $US401 billion, which represented 7.3 percent of the GDP. Psychiatric 
disorders, at $136 billion, represented 34 percent of total estimated costs in the Lewin/ICF
 Report. 34 percent x 7.3 percent = 2.48 percent of GDP. 
22. Data from the Australian Bureau of Statistics. 

Human Rights and Equal Opportunity Commission Page 839 

23. Andrews et al, op cit. In 1985 Andrews and colleagues estimated that schizophrenia cost each 
person in Australia $US29 in 1975 dollars. To calculate the total cost in 1992 Australian dollars,
 the current exchange rate of .715 Australian dollars to 1 US dollar (7 October 1992) was used, as
 was the total Australian population of 16,849,449 (ABS-1992) people and the adjustment in the 
Consumer Price Index. The June quarter CPI in 1975 was 28.4 in comparison to the June 1992 CPI of 
107.3; this represented a 277 percent increase n the CPI during that time. 
24. Prof G Burrows, Professor of Psychiatry, University of Melbourne and Chairman, Mental Health 
Foundation of Australia. Oral evidence, Melbourne 9.4.91, p220. 
25. Comprising $3.9 million NHMRC Psychiatric & Psychology Project & Unit Grants; $1.0 million 
Clinical Studies Unit Queensland; $1.7 million Victorian Government, including funding for the 
Mental Health Research Institute; $1 million from the Victorian Health Promotion Foundation; and 
$602,000 from the Health, Housing and Community Services Research and Development Grants. 
26. These figures do not include funding by State health departments of some research and prevention
 programs or mental health promotion activities and research. These are more difficult to quantify 
but should be taken into account in the overall picture of research development in this field. 
27. Independent Commission on Health Research for Development.op cit. 
28. An increment of more than $20 million on the current psychiatric funding base would overextend 
the existing psychiatric research infrastructure and result in an inability to efficiently and 
economically utilise the increased funding base. However, it is clear that incremental goals, 
perhaps of the order of $2-3 million per annum (in real terms) over the next 8 to 10 years, would
 bring psychiatric research funding into a range which would be justified by the cost to the 
community of these diseases. 
29. Australian Institute of Health and Welfare, Australia's Health, Australian Government Publishing 
Service, Canberra,1992. The Institute is based in Canberra but also has four external Units and has
 developed formal collaborative arrangements with three other Agencies. 
30. In late 1992 the Australian Bureau of Statistics introduced an annual survey of private hospitals
 in Australia. Data from this survey, when combined with public sector health data from AIHW, will 
form the basis of the first set of national statistics relating to hospitals. 
31. The AIHW works closely in association with the Australian Bureau of Statistics which conducts 
five-yearly censuses, as well as periodic National Health Surveys, surveys of disability and aging 
and of private health insurance. 
32. Formerly the Department of Health, Housing and Community Services. 
33. A total of 92 projects were funded. 
34. NHMRC Research Evaluation Management Committee, Allocation of Resources to 
Disciplines 1979-89, AGPS, Canberra, 1990. This contains an extremely comprehensive analysis of 
funding success rates by psychiatric and psychological researchers applying to the NHMRC. 
35. R Kalucy, 'An Exploration of the Gap Between Aspiration and Success in Psychiatric Research 
Funding', Australian and New Zealand Journal of Psychiatry, vl7, 1983, pp373-382. This provides 
a detailed analysis of the gap between applications and grants in psychiatric research funding. 

Page 840 Mental Illness Inquiry 

36. ibid, p374. Another reason that there is a discrepancy between the success rates of other 
disciplines and psychiatry is that many of the successful disciplines have been funded by the 
NHMRC since it was established in 1937. Professor Kalucy points out 'They have received funding not 
only for projects, but also for Training Fellowships within Australia and overseas for many years. 
In many cases, their disciplines are led by scientists who are the fourth, fifth or sixth generation 
of full time scientists. Positions within these laboratories are fiercely competed for by scientists 
who are themselves full-time workers. 
They form a large community of well trained scientists who invest heavily in the training of 
their successors'. 
37. Webster, op cit, pp466-467. 
38. J Palca, 'National Institute of Health Strategic Plan Near its Final Form', Science, v257,
 1992, pp476-477. This issue was recently addressed by the National Institutes of Health in the 
United States (NIH). The NIH have developed a draft plan which attempts to reprioritise the 
relationship between individual investigator grants and goal-directed research directives,
 with greater emphasis being placed on 'research priorities the NIH hierarchy think are 
necessary to foster the country's physical and economic health'. It is not that the NIH do
 not recognise the importance of investigator-initiated research — the Institutes state, for
 example, that such research 'is at the heart of scientific enquiry in 
which discoveries arise in unexpected places, from improbable insights and through leaps of the
 imagination'. Such grants will continue to be allocated but will be seen within a broader 
context of 'the achievement of scientific goals and programs'. 
39. R Felix, Encyclopedia of Mental Health, ed. Albert Deutch, Franklin Watts Inc., v4, 1963.
 The US Selective Service system rejected 900,000 men for service because of neuropsychiatric 
disorders and more than 700,000 were discharged from the services as a result of these disorders. 
40. H A Pincus and T Fine, 'Anatomy of Research Funding of Mental Illness and Addictive 
Disorders', Archives of General Psychology, v49, 1992, pp573-9. 
41. id. 
42. In 1992, the Medical Research Council allocated 11.5 percent of its fund to these areas. 
43. To be included as a special initiative area, a clinical discipline must be of considerable
 importance to the Australian community and be considered to have limited chances of success 
in the project grant process. 
44. In contrast to block grants, which are awarded to Institutes which have been established
 for many years and have a record of excellence in research, special units are established to
 research important clinical problems and are centred around productive research groups which 
have not yet had the opportunity to develop the track record of major institutes. 
45. The Network proposal grew out of a desire to see psychiatric research taking place within 
a broader and more scientifically ambitious scope than the research which is currently conducted 
within individual units. It is also hoped that its creation will encourage neuroscientists not
 currently working on projects related to psychiatry to begin doing so.
46. G Parker, 'The Australian Contribution to Psychiatry', Australian Psychiatry in the 
Tradition of Aubrey Lewis, Cloister Press, 1991, pp29-38. 
47. The results of John Cade's studies are reported in the Medical Journal of Australia, 
September, 1949. 
48. A Reifman, R Wyatt, 'A Brake in the Rising Cost of Mental Illness', Archives of General 
Psychiatry, v37, 1980, pp385-389. 
49. A Henderson, 'Australian Research: Psychiatric Research in Australia', Australia and New
 Zealand Journal of Psychiatry, v!7, 1983, pp369-372. 

Human Rights and Equal Opportunity Commission Page 841 

50. Some of the reasons for this stark record have been discussed in the Introduction to this
 chapter. They include comparatively poor salaries, lack of identifiable long-term career 
structures, the extreme complexity of much psychiatric research and, until recently, the 
lack of psychiatric research centres and institutes where full-time research careers can 
be pursued in the midst of a 'critical mass' of research colleagues. 
51. National Health and Medical Research Council, Prevention in the Mental Health Field, op cit. 
52. NSW has a number of prominent research facilities such as the Psychoneurology unit at 
James Fletcher Hospital in Newcastle. 
53. There is a greater concentration of medical research in Victoria than in other States.
 The government has accepted responsibility for funding the Victorian Medical Research 
Institute's major infrastructure costs and successive Victorian Governments have taken 
the view that they should work with the Commonwealth to support the medical research being
 conducted in their region. This support has ensured that Victoria retains a high 
proportion of NHMRC Project Grants. 
54. The Institute's research programs will be consolidated when it moves from a number of 
buildings scattered around Royal Park to a purpose-built facility which will include 
state-of-the-art laboratories and neurophysiological and neuroimaging technology.The 
building will be funded from a combination of Commonwealth, State and private sources 
and will be completed by November 1993 
55. This figure includes staff salaries and clinical services. 
56. The Inquiry has been advised that discussions are under way in both New South Wales 
and Western Australia to establish research units similar to those in Victoria and Queensland. 
57. B Levin et al, 'A National Study of State-supported Psychiatric Research Institutes',
 Hospital and Community Psychiatry, v40, No 4, 1989, pp388-392. 
58. Copolov, op cit, pp67-68. 

Page 842 Mental Illness Inquiry 

Chapter 27 

PREVENTION AND EARLY INTERVENTION 

The prevention of mental disorders has been neglected but the public health burden 
now is too high for this to continue. Nearly one half of all mental and neurological
 disorders are amenable to primary prevention. Effective measures could be applied 
even in countries with few resources. By and large these measures all rely on available
 knowledge and commonly involve sectors other than health.1 

Prevention is critical to the whole area of mental health. While our knowledge 
of the causes of many conditions is incomplete, the scientific advances of recent 
years do provide us with many findings that, if systematically applied, could make
 a significant difference in the levels and severity of many mental health problems 
and some mental illnesses. Unfortunately, much of this knowledge has simply not been
applied to develop prevention policies and programs. 

Several recent international and Australian initiatives should, however, be 
noted. In the United States the National Institute for Mental Health (NIMH) has 
established an Office of Prevention, undertaken special research initiatives and 
recently released a number of policies and reviews. The US National Health 
Promotion and Disease Prevention Objectives, Healthy People 2000, have 
identified key mental health goals, including reduction of the prevalence of 
mental disorder in children, adolescents and adults living in the community. 
Similar prevention strategies have been developed in the UK, although in a 
more limited way. 

The World Health Organisation has also made repeated calls for recognition of 
the urgency of prevention initiatives in mental health — and support for 
prevention has increased among consumer organisations — both in Australia 
and overseas. 

Recent Australian initiatives have drawn together evidence on which to base a 
systematic approach to prevention.2 The development of a National Health 
Strategy for Australia3 has incorporated for the first time systematic Goals and 
Targets for Mental Health,4 with a program for implementation under the 
National Mental Health Policy. Thus there is now acceptance of the need for 
a national approach to the adoption of preventive programs. 

Clearly, if opportunities for effective prevention programs exist, but are ignored 
(or if acceptance of the need for them is not translated into reality), we are 
mortgaging the rights of those vulnerable to mental illness — and their families. 

Human Rights and Equal Opportunity Commission Page 843 

It should be noted that many of the issues addressed in this chapter draw on 
evidence analysed in earlier chapters of this report. 

Community Issues and Prevention in the Mental Health Field 

Community Understanding of Mental Illness 

Much of the evidence presented to the Inquiry highlighted the community's 
poor understanding of mental health issues and lack of compassion for people 
suffering mental illness. Chapter 14 portrays the impact of stigma, continual 
rejection and discrimination on those affected. This lack of understanding also 
makes it much more difficult for individuals to recognise and seek help for the 
early signs of mental illness — either for themselves, or for family members. 

Public education campaigns in the health area have contributed significantly to 
attitudinal change — promoting greater understanding of disability and general 
health (especially cardiovascular disease — 'Know Your Heart' and the 'Quit' 
campaign; and cancer — 'Cancer is a word, not a sentence'). Humanising the 
impact of illness by depicting real people and their experiences (in programs 
such as the HIV/AIDS discrimination campaign) has contributed to more 
tolerant attitudes and behaviour in the community generally, and to individuals 
affected seeking earlier access to effective prevention and treatment (a 
phenomenon particularly noticeable in breast cancer screening and pap smear 
campaigns). 

Several campaigns have addressed aspects of mental health and mental illness, 
but there is a compelling need for a sustained nation-wide campaign to educate 
our community about mental illness — to demystify it and ultimately to 
destigmatise it. This needs to build on initiatives such as Mental Health Week 
and the work of state and national Mental Health Associations, the Schizophrenia 
Fellowships and ARAFMI (through its school based education programs). 

Many witnesses emphasised that unsympathetic attitudes of the media, reflecting 
populist prejudices and misconceptions, added considerably to stigma and 
misapprehension about mental illness. 

• We as a family know the social stigma associated with mental illness. We all feel
 that the media portrayal of those with a mental illness does nothing to educate or
enlighten the general public. We hope that this situation will somehow be remedied 
in the future.5 
• People think that schizophrenia is a split personality... They've seen Alfred
 Hitchcock thrillers and Psycho movies, and they get an impression that we're 
generally dangerous.6 

Page 844 Mental Illness Inquiry 

• I think you have our submission and I think most of it is self-evident, but we do
 wish to point out the strong negative feelings that do exist against mental illness
 in the community which get reflected and exaggerated in the media.7 

Stigma 

As described in Chapter 14, social stigma associated with fear and misunderstanding
 may have an extremely debilitating effect. This is particularly 
significant in the context of prevention and intervention, since those who are 
vulnerable or mentally ill are profoundly influenced by these perceptions, 
compounding their low sense of self-worth and feelings of anxiety and 
uncertainty. 

According to the Schizophrenia Australia Foundation the 'human rights and 
fundamental freedoms' of people with serious mental illness are 'seriously 
jeopardised' by stigma — 'a mark of dishonour and disgrace'.8 

The negative effects of stigma and discrimination not only prevent early access 
to care and limit opportunities for treatment and recovery, they create 
difficulties in rehabilitation and community living. Stressful experiences of 
rejection therefore compound the problems of those with mental illness and 
significantly impair their mental health. 

Social Adversity 

The correlation between social adversity and some mental illness and disorder 
has been clearly established.9 

Poverty 

Social disadvantage inevitably means greater exposure to life's stress factors 
(stressors) and, for those affected by mental illness, it frequently precludes 
access to quality health care, decent housing, and employment. It is well 
established that general health is worse for the economically disadvantaged and 
that this can contribute to increased risk of mental illness (for instance severe 
depression). Disempowerment and lack of information may exacerbate the 
situation. It is also established that mental illness may lead to social disadvantage
 through downward social drift, incapacity to work, lack of access to adequate 
living standards and poorer quality of life. 

To give an idea of the sort of perception that becomes extremely difficult and 
involved for a schizophrenia sufferer, the best example I could think of is the 
poverty cycle. I know it's difficult for anyone in any situation to get over the... 
problem of a poverty cycle and the reality of it, but for a schizophrenia sufferer 
it's more complicated because of the sense 

Human Rights and Equal Opportunity Commission Page 845 

of blame, of failure in terms of that situation and then needing to get over that
 hurdle as well as the practical hurdle of the poverty itself. There are a lot of 
schizophrenia sufferers out there who have had employment positions and are finding 
it incredibly difficult to now find employment — not because, perhaps, they're not 
offered jobs in many cases, but simply to get over the perception of having failed.10 

Unemployment 

Unemployment is a particular stressor, both for the mentally ill and those who 
are at risk of mental illness. It may lead to, or exacerbate depression, anxiety 
and other mental disorders. The most recent research has indicated very adverse 
effects on health generally — and mental health in particular.11 

Recent studies have also indicated that more than 50 percent of unemployed 
young people suffer from depression.12 Research has not yet established the 
effects on mental health of long-term unemployment, or second generation 
unemployment. However, a 1993 review of statistics on unemployment 
indicated that 18 percent of young people in Australia are growing up in 
households where no-one has a job.13 12 percent of young people who are 
unemployed themselves have a parent or parents who are unemployed — ie they 
are second generation unemployed. This review described the alienation, 
disadvantage and despair faced by this growing 'underclass'. Clearly, it is 
imperative we use our mental health expertise, as well as broader social 
programs, to assist the tens of thousands of our young people so adversely 
affected. 

High unemployment means diminished opportunities for maturation and growth 
for adolescents. As discussed in Chapter 13, mental illness may significantly 
interfere with their capacity to pursue education or training to equip them for 
later life, or may more generally inhibit maturation. As established earlier in 
this report, the onset of mental illness is often in late adolescence, before 
education has been completed, tertiary studies or training undertaken and work 
commenced. Thus young people who are affected may be much more vulnerable 
to unemployment as well. 

Socio-cultural Factors and Vulnerability. 

Cultural factors influence perceptions and understanding of unusual behaviour 
and patterns of response and care. They are also relevant to preventing mental 
distress and mental disorder (as outlined below). 

As indicated in Chapter 23, Aboriginal and Torres Strait Islander people have 
totally different concepts of mental health and wellbeing. Continued lack of 
recognition of this fact will only perpetuate morbidity and inappropriate care. 

Page 846 Mental Illness Inquiry 



Understanding of culture is relevant in other contexts too. At least 20 percent 
of Australians are from non-English Speaking backgrounds (NESB) — either 
they or their parents have arrived in Australia from different cultures and 
language groups (see Chapter 24). 

Not only is an understanding of these cultural issues essential for the provision
 of mental health care, but unless care is provided in culturally appropriate ways
 additional stresses occur, adding to the burden, illness and disability of people 
affected by mental illness. 

Preventive strategies must therefore acknowledge the particular cultural 
experiences of different groups (the effects of colonisation, separation and 
cultural loss for Aboriginal people; the effects of migration, and resettlement 
or refugee status for people of NESB) to lessen the likelihood of mental illness 
developing. 

Aboriginal and Torres Strait Islander People 

The likelihood of mental health and social problems among Aboriginal and 
Torres Strait Islander people is greatly increased by social disadvantage, 
racism and discrimination. 

Many Aboriginal witnesses spoke of the long-term psychological effects of 
people being moved from traditional lands and separated from their families. 
The anger, grief and trauma resulting from the removal and institutionalisation 
of children was a recurring theme in evidence from Aboriginal witnesses.14 

Among Aboriginal communities, distress manifests itself not only in grief and 
depression, but also in antisocial and self-destructive behaviours, poor self 
image and chronic substance abuse. 

Older Aboriginal people have special needs, as do young people and women. 
An adequate understanding of the cultural contexts relevant for these groups 
(for instance Aboriginal 'women's business' and reproductive health) is a 
prerequisite for effective preventive mental health programs. 

While the development of specialised mental health services for Aboriginal 
people has been a low priority, recent studies15 and a planned conference, Our 
Way (the first National Aboriginal Mental Health Conference to be held in 
Sydney in November, 1993) should contribute significantly to our capacity to 
address these issues. 

Human Rights and Equal Opportunity Commission Page 847 

There is an urgent need for Aboriginal people to be involved in the development 
of their own preventive mental health programs. These should build on 
what is known about trauma and loss, enable Aboriginal people to develop 
counselling and support programs related to these issues, and inform the design 
of services to mitigate the effects of disadvantage and deprivation. 

The high mortality rate experienced by Aboriginal people is another important 
factor. Families are stressed by multiple and premature bereavements, as well 
as unresolved grief from earlier generations. The stresses faced by youth, the 
problems that arise from substance abuse, domestic violence and family 
breakdown, and the effects of marginal status and lack of access to services in 
rural and isolated areas must also be addressed. 

There is evidence to suggest that prevention programs developed by and with 
indigenous peoples can be successful in lessening vulnerability and 
morbidity.16 

Whilst it is now accepted that Aboriginal people suffer from psychiatric afflictions,
 recognition, assessment and management of these illnesses in Aboriginal people is 
different — because of their disadvantaged situation and because of the non-European
 styles in which they sometimes present... There are no specific policies for the 
diagnosis and treatment of Aboriginal people with mental illness.17 

It is essential that support be given and research undertaken to develop mental 
health prevention programs that are culturally relevant for Aboriginal people. 

People of Non-English Speaking Background 

As outlined earlier in this report,18 a range of factors relating to 'interpretations'
 of mental illness, cultural practices towards the mentally ill, and traditional or 
cultural healing processes and practitioners are relevant for people from different
 ethnic, racial and religious backgrounds. To provide effective prevention programs 
these issues need to be taken into account. 

Such programs should facilitate early recognition and treatment of mental 
illness and may need to include education of the leaders and practitioners 
dealing with each group.19 

Dealing with life crises such as bereavement, which may precipitate mental 
health problems such as severe depression, may be determined by specific 
cultural prescriptions. These may assist resolution and recovery (for instance 
by supporting the grieving process), or may inhibit it. If culturally appropriate
 practices are not able to be carried out, this may further complicate adjustment 
to major life events, increasing the risk of mental illness. Clearly, prevention 

Page 848 Mental Illness Inquiry 

programs need to take such issues into account, and to ensure that crisis 
resolution is supported in culturally appropriate ways. Similar principles
 apply in relation to developmental transitions (eg adolescence) and psychological 
vulnerabilities associated with them. 

Language is a key factor, influencing not only understanding of individuals' 
distress, but also their access to direct services or prevention programs. As a 
key element in preventing distress and illness and assisting individuals from 
different cultural and linguistic backgrounds, it is essential to ensure that 
culturally specific information is provided and bilingual practitioners or 
trained health care interpreters are available. 

As noted in Chapter 24, refugees are particularly vulnerable and may be 
suffering from overt or covert mental illness, such as post traumatic stress 
disorder, as a consequence of their experiences. While several Torture and 
Trauma Services exist, it is essential that early recognition and care is 
encouraged, in supportive ways which take into account the special vulnerabilities
 of this group. If this does not occur, secondary traumatisation is likely — 
so a preventive approach is particularly important. 

Elderly people of NESB have also been identified as a vulnerable group and a 
preventive approach is likely to be helpful. Women of NESB have been 
identified as at risk of mental disorder through their isolation, lack of social 
networks, changed cultural norms concerning the place of women, adverse 
work environments (or lack of access to work), and lack of opportunities to 
learn English (see also Chapter 24). Clearly, preventive strategies for women 
in such settings could significantly diminish their risk of developing mental 
health disorders. 

Evidence to the Inquiry clearly indicated that failure of assessment and 
diagnosis, and inappropriate treatment, occur when systems of care are not 
culturally and linguistically appropriate and attuned to these issues. The 
evidence also suggests some people of NESB are more likely to be admitted to 
acute psychiatric care, and may be held longer without appropriate treatment, 
further compounding their problems. Clearly, prevention for people of NESB 
must address these issues. 

Human Rights and Equal Opportunity Commission Page 849 

Opportunities for Prevention in Specific Contexts 

Children and Adolescents 

As noted in Chapter 20, the extent of psychological disorder affecting children 
and adolescents is substantial — with approximately 15 percent suffering 
significant psychological morbidity. 

Emotional and behavioural problems are often difficult to diagnose and may 
merge with distress related to children's experiences and family setting. Not 
only may such problems significantly interfere with a child's wellbeing and 
development, but they may also continue into adolescence, or indeed constitute 
the basis for mental illness or disorders in adult life. 

Many witnesses to the Inquiry emphasised the importance of preventive programs 
for children and adolescents. 

A logical next step is for additional funds to be allocated (not reallocated) for
 extensive and sustained primary prevention and early intervention program aimed at 
preventing the development of mental disorder in at risk groups. Examples of
 programs would include stress management, loss, grief and bereavement, education 
and assistance, early screening for children at risk of developing personality 
disorders, and people who have suffered from sexual and physical trauma.20 

The importance of early and effective treatment of children and adolescents in 
preventing adult disorder was particularly emphasised by expert witnesses. 

So, we've got the opportunity, in treating children, to prevent some adult mental
 illness; certainly not all, but some.21 

Factors associated with behavioural and emotional problems in childhood and 
adolescence are usually generic — that is they predispose to disorder generally, 
rather than to a specific condition. It is also likely that multiple factors will 
interact to lead to distress or disorder. These include: parental discord; 
parenting difficulties; loss of a parent or parents through death, separation or 
divorce; other stressful events; physical, emotional or sexual abuse; parental 
illness, psychiatric or substance abuse such as alcoholism; genetic vulnerability; 
biological factors affecting the development or function of the brain, for instance 
during pregnancy, childbirth, infancy or childhood; and temperament, (ie the child's 
particular psychobiological responsiveness and make up, and his or her interaction 
with parents or other carers and their environment). These areas of potential 
vulnerability may be balanced by elements of resilience and competency — and 
prevention may also involve enhancing these.22 

Page 850 Mental Illness Inquiry 

A number of recent studies have underlined the need to develop prevention 
programs for child and adolescent mental health. In the US, the Office of 
Substance Abuse Prevention and the American Academy of Child and 
Adolescent Psychiatry have produced a substantial review of all available 
scientific data that would constitute a basis for such prevention.23 Other 
reviews also highlight opportunities in this field.24 In Australia, a recent 
review of the Scope For Prevention in Mental Health25 detailed potential 
prevention initiatives and their rationale. In the US the Goals and Targets in the
 National Health Strategy identify mental health prevention goals for children and
 adolescents; and the recent Health Goals and Targets in Australia, suggest growing 
recognition of the need for substantial prevention strategies for child and adolescent 
mental health.26 

Parental or Marital Discord 

There is a great deal of evidence concerning the distressing and disturbing 
effect that parental arguments and domestic violence have on children — with 
work from many senior child psychiatrists suggesting that this is one of the 
more powerful negative influences contributing to child psychopathology. Such 
problems often do not occur in isolation. Indeed, they are frequently associated 
with other factors, such as parental alcoholism. There is evidence that a number 
of prevention programs can enhance marital harmony27 and therefore mitigate 
this contributing factor. Clearly, it is essential that programs of this kind are
 developed, implemented and evaluated. 

Effective Parenting 

Effective parenting has been the goal of many programs — from those 
providing support during the antenatal and post-partum period, to those which 
teach specific parenting skills. Such programs have also been developed for 
vulnerable groups (such as single parents) and interventions designed for people 
in difficult parent-child settings (highly anxious mothers or parents with 
premature, low birthweight babies).28 

In all cases, benefits have been demonstrated in sound scientific studies, and 
there is clear evidence that preventive programs of this kind mitigate later 
problems for children.29 

Childhood Loss and Separation 

Not only are loss and separation distressing for children, they may also lead to 
short or longer term vulnerability to a range of associated problems, including 
depression. 

Human Rights and Equal Opportunity Commission Page 851 

Counselling for bereaved children and families, as well as prevention and 
support programs for children who have been traumatised, are likely to produce 
more positive results in terms of better adjustment and lesser vulnerability30. 
A number of US studies have demonstrated the benefit of preventive interventions 
with families following divorce — a frequent trauma with one in three 
marriages now ending.31 While it is true that many children may be more 
adversely affected by continuous parental discord than by the family break-up, 
there is, nevertheless, a great deal of grief and adjustment to be dealt with in 
this context. 

Child Abuse 

Prevention programs relating to child abuse are essential — in view of its very 
serious impact on children and adolescents and the contribution of abuse to 
vulnerability to psychiatric illness in adult life — demonstrated in evidence 
presented to the Inquiry. Intervention in high risk parenting situations32 may 
diminish the risk of physical abuse in infancy, so such programs should be a 
priority. Further public awareness programs emphasising the importance of 
preventing abuse are also necessary, as is research to identify causal factors 
and effective ways of altering these.33 

Early and effective treatment of sexually abused children may lessen the risk 
of depression and post traumatic stress disorder (PTSD) in this group.34 
Breaking cycles of abuse — with the long-term aim of preventing the abused 
child becoming an abusing parent (as one in five may do) — is also critically 
important.35 

Programs are also needed to address the role of violence in contributing to the 
mental health problems of children and families. This can contribute to mental 
ill health through the effects of domestic violence on the mother (which is 
frequently witnessed by children), as well as the child's direct suffering. Not 
only may the child be traumatised, but it may also identify with the violent 
person and be more prone to violent behaviour in childhood, or later life. 

Portrayals of violence on television or videos may contribute by 'sanctioning' 
violent solutions. The whole issue of preventing violence and abuse is relevant 
for mental health generally and demands a preventive approach,36 as indicated 
by recent reports.37 

The Children of Parents with Mental Illness 

Evidence to the Inquiry highlighted the problems of children whose parents are 
mentally ill. (Chapter 16 addresses these issues in detail.) Such children are 

Page 852 Mental Illness Inquiry 

vulnerable to stigma, rejection, loss, disruption, lack of understanding, 
depression, grief and fear. (In some instances genetic and other vulnerabilities 
are also relevant factors.) They may also have to take premature responsibility 
for a mentally ill parent and care for younger siblings, especially if the partner has
 left.38 

Many professionals in the mental health field are now recognising the special 
vulnerability of such children and the need to provide prevention programs that 
directly address the problems of impaired parenting that may accompany mental 
illness.39 

The President of the Coalition of Child and Adolescent Mental Health 
Professionals advocated: 

1. Programs which provide support and education to children and families while the ill parent
 is being treated as an inpatient in a psychiatric hospital. 
2. Programs which provide support and education to children when their parent is 
receiving ongoing treatment/support as an outpatient of a community facility such as a 
community mental health centre. 
3. Special assistance for children who appear to have psychiatric, emotional and/or 
behavioural problems whether these arise from genetic and/or environmental vulnerability.40 

The Inquiry supports the value of such an approach, especially as these young 
people are potentially in contact with the mental health care system. 

Enhancing Resilience and Competence 

Programs designed to increase adolescents' competencies, even when they are 
vulnerable, are believed to enhance cognitive problem-solving, self esteem, 
understanding of interpersonal relationships,41 social skills and other attributes. 

Existing frameworks, such as personal development programs in schools, can 
be valuable in this context.42 Programs targeted to special groups, or for 
special purposes (eg school transitions) have been demonstrated to have 
substantial benefit, especially when complemented by educational programs 
addressing socioeconomic and other disadvantage.43 

These generic issues need to be addressed to ensure the rights of children and 
adolescents, and to decrease their vulnerability to psychiatric disorder in 
childhood and later life. But it is also essential that children have access to 
effective specialised treatment to ensure recovery when disorder does occur. 

Human Rights and Equal Opportunity Commission Page 853 

Several specific issues warrant special attention: 

1. Youth suicide is increasing alarmingly and expert evidence highlighted the 
need for prevention programs. 

The prevention strategies target youth in general and try to prevent the occurrence of 
precursors of suicidal behaviour, and they might include things like self esteem courses,
 providing crisis counselling, training for health staff or education staff and so on, 
setting up peer support systems. 

Intervention strategies include things like hotlines and suicide crisis counselling so,
 post-attempt counselling, I should say, and postvention strategies deal with the 
aftermath of suicide. So that's when school staff and students for instance, after 
a suicide, have special consultation to debrief, to identify people, kids who might
 be at risk, to receive information about resources, mental health resources, and
possibly help about stress management.44 

While it is not yet clear how effective these programs are, the rising rates of 
suicidal behaviour among young people (considered in Chapter 20) make it 
essential that this issue is addressed. A review of various types of programs 
indicates there is no easy answer, but it is essential that any suicidal behaviour
 is taken very seriously, thoroughly assessed in terms of underlying psychiatric 
problems, and appropriate treatment instituted.45 To date this is the most effective
 form of prevention. 

2. Depression in young people is an increasingly frequent and often poorly 
recognised problem. Recent studies indicate it occurs in mild, moderate or 
severe forms in 14.6 percent of adolescent males and 25.2 percent of adolescent 
females. It is likely to be associated not only with risk of self destructive 
behaviour such as suicide, but also substance abuse, eating disorders and 
delinquency.46 Prevention initiatives include dealing with stressful life crises 
such as bereavement, the generic issues outlined above, issues of gender 
specific stresses and self esteem which appear relevant to the heightened rates 
in girls, and the effects of parental disorder. 

US initiatives addressing depression have been formulated into a national 
campaign, DART (Depression Awareness Recognition and Treatment),47 to 
promote early and effective treatment and prevent the related human and 
economic costs and suffering. Depression in young Australians clearly also 
warrants a systematic prevention approach. 

Page 854 Mental Illness Inquiry 



3. Conduct Disorder and other disruptive behaviours are a source of 
considerable morbidity in child and adolescent mental health, with problems 
occurring in 3.2 — 6.9 percent of young people.48 Chronic illness and 
associated disability may lead to impaired self esteem, poor performance at 
school — and to aggressive and behavioural disturbance as a consequence. 
...and of most concern, aggressive and learning disabled children will not be 
treated at an early stage, resulting in alienated kids, becoming street kids with 
increasingly antisocial behaviours in the community...49 

Poor parenting, including rejection, lack of involvement and supervision of 
children, large family size, household disorganisation, and marital disharmony 
all increase risk — as do disadvantaged socioeconomic circumstances. (Children 
who are vulnerable because of such influences may also be vulnerable to 
television violence and its effects.)50 

A Canadian psychiatrist who has conducted extensive research and clinical work 
with children and adolescents with disruptive and antisocial behaviours has 
concluded that effective prevention strategies include programs targeted for 
children and families at high risk, behavioural family intervention, and other 
programs instructing parents and teachers in dealing with children's aggression 
and disturbed behaviours.51 

Recent overseas research has identified multifaceted programs targeting multiple 
risk factors as the most effective for children living in high risk settings.52 
These findings have also been reinforced by Australian research.53 The 
importance of prevention in this sphere has been recognised by identifying the 
prevention of conduct disorders as one of the primary aims in our National 
Goals and Targets for Mental Health.54 

Prevention of conduct disorders in childhood and adolescence, or their early 
and effective treatment, is of special significance given the great personal, 
social and economic costs produced by antisocial behaviour and other disorders. 
Large scale epidemiological studies in the US55 have established that conduct 
problems correlate with increased numbers of these and 'externalising' 
disorders (eg delinquent, acting out behaviours) in later childhood and 
adolescence, and antisocial personality disorder in adult life (especially for 
men). These conditions contribute significantly to depression, suicide, substance abuse, 
violence and other adult disorders — and, more generally, to community dysfunction. 

4. Youth Homelessness is often associated with deprivation, violence and 
exploitation and this risk is heightened if the young person is affected by mental 
illness. Homeless young people are frequently from disrupted families, may not 

Human Rights and Equal Opportunity Commission Page 855 

access health or mental health services, may be at risk of HIV and other 
sexually transmitted diseases, and may also use a wide range of drugs.56 
Poverty, dropping out of school and general deprivation are compounded in 
such circumstances. Prevention initiatives must therefore be oriented to 
preventing homelessness wherever possible — and ensuring a range of properly 
coordinated responses if it does occur.57 

5. Young people are particularly vulnerable in their early encounters with 
our criminal justice system. Every effort should therefore be made to deal 
with the psychological issues and risk factors without resorting to incarceration
 — with the extremely negative results this often entails.58 

Aboriginal young people may be particularly at risk in terms of both cultural 
deprivation and associated stresses, and their generally disadvantaged position. 
It is essential that special resources and programs are provided for them. 

Finally, because the years of later adolescence are the time of onset for many 
major mental illnesses, these special vulnerabilities must be recognised and 
specialised prevention, early intervention and treatment approaches developed 
to respond to early warning signs. Opportunities exist through schools (which 
exert a substantial influence on many young people), health care systems and 
community and home-based approaches. Many programs demand a multifaceted 
framework — involving the young person, parents, school and community — 
to be really effective. Prevention will always need to take into account and 
support positive family attachments, and build on the strengths which the young 
person has. 

Prevention and Serious Mental Illness 

Evidence before the Inquiry highlighted the suffering and disability caused by 
serious illnesses such as schizophrenia, bipolar disorder (manic-depressive 
illness) and depression. Not only do these illnesses themselves exact great 
costs, but the trauma involved in the illness and the responses to it may cause 
further adverse outcomes, such as post traumatic stress disorder or secondary 
depression. 

Family members and carers may be so stressed that they themselves develop 
disorders (such as anxiety and depression) as a result of their burdens of care 
(see also Chapter 15). These problems show up in many ways and are further 
aggravated if the affected individual does not receive the earliest appropriate 
treatment. 

Page 856 Mental Illness Inquiry 

As the specific causes of serious mental illness have not yet been clearly 
identified, it is often not possible to prevent their development. Nevertheless, 
as with heart disease, many contributing factors which increase risk are now 
understood and it may be possible, in many instances, to lessen risk by 
mitigating these factors. As with heart disease and cancer, early detection and 
treatment before the disorder becomes consolidated with ongoing disability and 
secondary morbidity is critical to preventing the most adverse outcomes. There 
is now a substantial scientific basis for early detection and intervention 
programs for serious mental illnesses and also for other prevention approaches. 
However, few such programs are currently in place in Australia. 

Schizophrenia 

While researchers are still attempting to identify the factors that may contribute to
 the development of this illness, there are several areas where a preventive approach
 appears to be helpful. 

Early Detection and Intervention 

Psychiatrists working with general practitioners in an English community have 
been able to detect the earliest signs of schizophrenia — and with education, 
supportive interventions and short-term psychotropic medication — prevent the 
onset of an episode, leading to a much lower than expected rate of schizophrenia 
in the area involved.59 Obviously this research must be repeated and tested 
in different settings, including Australia, but these early findings are encouraging 
and warrant urgent attention. (The Early Psychosis Centre,60 recently established in
 Melbourne, will provide the opportunity to study and work with people in the earliest
 stages of psychotic illness and, hopefully, prevent onset in at least some cases or 
promote the fullest possible recovery in others.)61 

Prevention of Relapse and Further Episodes 

It is now well established that individualised assessment and therapy programs 
providing education and support, medication as appropriate, and suitable 
rehabilitation regimes will enhance recovery and lessen the risk of future 
episodes, or enable their early and effective treatment. This may include 
recognition of the particular 'signature' of symptoms for each person's pattern 
of relapse — assisting them and their families to understand and rapidly respond 
to such early indications. 

Human Rights and Equal Opportunity Commission Page 857 

Prevention of Traumatisation and Other Secondary Problems 

Many witnesses described the traumatic experiences associated with psychiatric 
treatment. (See particularly Chapter 8 — Inpatient Care and Treatment.) 

Studies have demonstrated that many people with serious mental illness may be 
so traumatised by these experiences, that they develop post traumatic stress 
disorder. This condition has symptoms which may lead to continuous reexperiencing
 of the trauma, numbing and withdrawal from others, and chronically heightened levels
 of arousal — with disturbed sleep and concentration, hypervigilance and bouts of
 irritability and anger.62 

Other studies have also indicated high levels of comorbidity with post traumatic 
stress disorder in those admitted to psychiatric care63 (which may reflect 
illness-related, as well as other traumatisation). 

Depression may also appear with awareness of changes in mental functioning 
and insight into illness processes or the recovery phase after the first acute 
episode.64 Thus depression and its causes should be looked for and preventively 
managed, especially as it may contribute to heightened risk of suicide or to 
difficulties of recovery. 

Preventive Approaches for Families and Carers 

While prevention programs for carers have not yet been studied systematically, 
evidence presented to the Inquiry clearly established that they often suffer 
severe stress and mental health problems and need education and support to 
prevent these (see Chapter 15). 

It is essential that education, support, respite and close interaction with 
professionals is provided — as well as specific prevention approaches to lessen 
the risk of significant mental health problems for carers of people with 
schizophrenia or other serious illness. 

Preventive Role of Community Organisations 

Organisations such as Schizophrenia Fellowships and ARAFMI, which are 
involved in community education and support of consumers and their families 
and carers, also have a major prevention orientation. Clearly, however, these 
organisations need to be adequately resourced. 

Page 858 Mental Illness Inquiry 

Depression and Bipolar Disorder 

While the Inquiry received less direct evidence concerning depression, it is 
nevertheless a frequent and severe mental disorder and one associated with 
considerable human suffering, economic costs, general health care utilisation 
and increased mortality (especially from suicide). As noted earlier, it may also 
occur secondarily with other mental illnesses. 

Early Detection and Treatment 

Major programs to assist in recognition and early treatment of depression are 
underway in the UK65 and in the US66 — but there have been no similar 
initiatives in Australia. 

Overseas evidence (from the UK and especially Sweden) indicates that 
depression is frequently not recognised by doctors. Enhanced recognition can 
be achieved by better education of GPs and appropriate screening — to 
facilitate treatment and referral.67 

A recent Scandinavian study demonstrated such initiatives could lessen levels 
of depression in the community and decrease suicide rates and health care 
utilisation.68 The benefits of earlier and more effective treatment in preventing
 depressive suffering, and its associated human and economic costs, should therefore
 be actively addressed with appropriate programs in Australia. 

Prevention of Bipolar Disorder 

Evidence has shown69 that lithium has contributed very significantly to the 
prevention of episodes of bipolar or manic depressive illness.70 Education of 
those affected and their families to enable them to recognise symptoms and 
patterns of relapse, and the need for care and treatment during an episode, can 
also produce more positive outcomes. 

Prevention Programs Oriented to Life Crises 

There is considerable evidence that loss (bereavement) and other stressful 
events (divorce, illness, accidents, unemployment) may precipitate depression, 
anxiety and other psychiatric problems. A large number of preventive 
counselling, education and support programs have been tested and found to be 
effective in lessening the risk of depression in these circumstances — and 
increasing the likelihood of positive outcomes.71 

Human Rights and Equal Opportunity Commission Page 859 

Self-help and community organisations (eg Sudden Infant Death Syndrome 
Groups) have also made substantial contributions to effective prevention in this 
area. Clearly there should be policies and programs to help prevent depression 
wherever possible. 

Prevention Related to Earlier Vulnerability 

As noted previously, children whose parents are psychiatrically ill, or suffer 
from depression, may be at particular risk. Those who experienced depression 
in adolescence may be more at risk in adult life. Parental loss, parental 
alcoholism, family discord, childhood separations and a range of other 
experiences and states (eg low self esteem) may predispose to depression in 
adult life. Prevention programs should therefore aim not only to care for and 
support vulnerable children, but to lessen their vulnerability to depression in 
later life.72 

Post natal depression may also increase vulnerability — and like all adult 
problems which potentially impact on children, should be rapidly and 
effectively treated. 

Post Traumatic Stress Disorder (PTSD) 

Although not canvassed widely in evidence to this Inquiry, PTSD is a frequent 
and severely disabling condition, affecting at least 1 percent of the community 
and 15 percent or more of those who have been severely traumatised73 (and 
often also complicating other disorders). Prevention approaches range from 
preventing trauma and violence in the first place, to the provision of debriefing,
 counselling and other brief interventions, education, and treatment programs. 
Self-help organisations (ranging from Victims of Crime Associations to the Vietnam 
Veterans' Counselling Services) have all made a positive contribution in this context.74 

Groups Which Are Particularly Vulnerable 

Prevention programs for groups which are particularly vulnerable should 
address relevant social contexts, and associated factors (such as disadvantage 
and stigma) where they exist. They should also develop preventive strategies 
to ameliorate particular risks for the group involved. 

Page 860 Mental Illness Inquiry 

Elderly People 

While there are some preventable dementias, (those related, for instance, to 
folate deficiency and dementia associated with vascular disease can be treated 
and dementia outcomes prevented) our current state of knowledge does not 
provide opportunities for prevention of conditions such as Alzheimer's disease, 
which is responsible for most dementia related morbidity in the elderly. (See 
Chapter 17 — Elderly People.) 75 There is, however, considerable evidence 
to suggest that in the early stages people experiencing dementia may be 
distressed by the changes in their mental functioning and may also experience 
depression and anxiety, so that supportive management (addressed in Chapter 
17) may help to prevent these secondary problems, even though not preventing 
dementia itself. 

As established earlier in this report, depression may be confused with dementia, 
or may not be diagnosed in the elderly and thus not adequately addressed. 
Effective early intervention with older people experiencing a depressive episode 
in relation to life stresses such as bereavement, or stroke, may prevent 
chronicity and assist recovery. 

Carers of the elderly, frequently daughters or women relatives, but also 
husbands of elderly women with dementia, are likely to be highly stressed by 
the burden of care. Preventive programs involving information, education and 
support have been demonstrated to be effective in diminishing the risk of 
psychiatric morbidity in those caring for dementia patients,76 as has institutional 
care where dementia is severe.77 (Burdens on professional carers also need to be 
addressed with programs to prevent burnout.) 

Supportive counselling through later life transitions such as bereavement78 and 
illness is likely to prevent psychological morbidity, such as anxiety or 
depression, which are common for elderly people in these circumstances. 

Another issue creating morbidity in the elderly is the often excessive and 
prolonged prescription of psychoactive drugs, which may lead to states of 
confusion, falls and other injuries. Education of general practitioners, 
physicians and others who care for the elderly is a critical aspect of prevention in this area. 

In summary, much distress and suffering among elderly Australians can be 
prevented — if their needs and rights are properly recognised and responded to. 

Human Rights and Equal Opportunity Commission Page 861 

Homeless People 

As noted in Chapter 18, the homeless are transient and unlikely to receive 
proper and continuous care (including appropriate medication). They are also 
vulnerable to violence, physical health problems and suicide. They may be 
young, sexually abused, involved in prostitution or injecting drug use, and 
suffer stigmatisation and discrimination for all these reasons. 

Accommodation, crisis support, access to appropriate mental health services 
(community and inpatient) and rehabilitation are essential. (Within this group, 
young people, women and children, and Aboriginal adolescents may have 
additional special needs, as may non-English speaking background youth.) 

Homelessness itself is so stressful that it is likely to add significantly to the 
disturbance and suffering of the mentally ill. Conditions in shelters and refuges 
may exacerbate mental disorders. Further problems arise because there is often a 
denial of the extent of homelessness, as well as the needs of the homeless — because
 bureaucracies are not geared to deal with the homeless, nor the homeless to 
interact with them. As indicated in Chapter 18, many of those 
directly involved with homeless people do not understand mental illness or do 
not have adequate staff or resources to address it. Poverty and alienation further 
afflict this group, and difficult economic and social conditions often add to their
 burdens. 

Homelessness and mental illness are causally interrelated — so prevention 
programs addressing the former will have some impact on the latter. 

Women 

Chapter 19 outlines special aspects of vulnerability for women with respect to 
mental health. Broad issues such as gender inequity may well contribute to low 
self esteem, the higher rate of depression experienced by women, and violence. 
While the women's movement, anti-discrimination legislation, affirmative action 
and equity policies have attempted to address these issues, a great many aspects 
of inequity are internalised in values and social structures and are resistant to 
change. Whether changes will prevent adverse mental health effects remains to 
be demonstrated. Nevertheless, addressing equity should be a central consideration 
in prevention — because of its profound and pervasive effects on mental wellbeing. 

Poverty disadvantages both women and their children — with negative effects 
for the mental health of both. Single parent households constitute a particular 
group with special needs, and there is evidence of effective preventive 

Page 862 Mental Illness Inquiry 

programs79 which may lessen the risk of mental health problems in some 
circumstances. However, these should only be seen alongside appropriate social 
action to redress issues such as poverty and associated adversities (including 
poor access to education, health and housing). 

Another important factor for women is their psychiatric vulnerability as a 
consequence of a past history of abuse and their vulnerability to abuse by 
treating therapists or within a health care system.80 Continuing education, 
strict professional standards and review and more effective complaints 
mechanisms may help reduce the latter; but, as noted earlier, prevention of 
child abuse and its enduring consequences must be acknowledged as one of the 
most serious challenges facing our society. 

Programs to enhance detection and management of domestic violence when 
people affected present to health care systems are currently under way81 and, 
if persevered with, should lead to better health and mental health outcomes for 
women in such circumstances. 

As noted earlier, women may experience psychiatric disorder as a consequence 
of violence (for instance post traumatic stress disorder following rape). 
Available evidence suggests that 97 percent of women do so in the first month 
and 47 percent even six months later.82 There is also evidence that preventive 
counselling may be effective in preventing such outcomes.83 It is critical, then,
 that women who need them have access to such programs, that they are not 
labelled as mentally ill when showing a normal stress reaction to such trauma, 
and that prevention programs are provided so that long-term morbidity is 
avoided. 

Also mentioned previously, the risk of post natal depression is increased by 
stress during pregnancy or delivery, depressive symptoms during pregnancy or 
a past history, and other factors unique to particular women, including 
nonsupportiveness or absence of a partner. Not only are women at risk in the 
post natal period, but their personal relationships may be substantially damaged, 
as may the development of their child. Preventive programs should increase support
 through pregnancy and the post partum period, and enhance the skills of those 
looking after the woman and her baby to detect this illness in its earliest stages
 and provide effective treatment. The role of self-help and support groups such as 
PaNDa is extremely important. 

As noted in Chapter 19, women also run the risk of being diagnosed as neurotic 
when they are not, or being prescribed tranquillisers rather than receiving 
appropriate assessment and counselling to deal with, for example, environmental 
stressors which they experience. Women also perceive themselves as being 

Human Rights and Equal Opportunity Commission Page 863 

labelled dysfunctional because they do not conform to certain social and sex 
role stereotypes. Preventive programs should be developed to ensure prevention 
counselling, stress management, social network development and support, self-
care, relaxation and assertiveness skills. There is substantial evidence of the 
effectiveness of such interventions in lessening women's risk of psychiatric 
disorder.84 

People with Dual or Multiple Disabilities 

Effective preventive programs for people with dual or multiple disabilities 
necessitate recognition of comorbidity in groups such as those with intellectual 
disability and mental illness, substance abuse and mental illness, deafness and 
mental illness, head injury/brain damage and mental illness, and HIV/ AIDS and 
mental illness. Early detection and diagnosis, as well as treatment taking into 
account the multiple issues involved are critical. Involvement and effective 
coordination of relevant services is essential to achieving such goals. 

Forensic Patients 

As indicated in Chapter 25, many factors may contribute to patients entering 
forensic facilities. The forensic system also creates stresses for patients which may 
increase their mental health problems. 

Untreated mental illness, despair and demoralisation may be so profound that 
suicide results. Trauma and violence may compound psychiatric problems and 
substance abuse is also frequently a problem. 

To be effective, preventive programs need to address both the service aspects 
(such as provision of specialised mental health assessment and treatment at the 
earliest opportunity) and particular strategies for those with 'high risk' 
indicators (such as young Aboriginal people). Policy reforms are necessary to 
ensure rights to treatment for those in prison or in police custody. 

Because of the special factors which affect Aboriginal people, prevention must 
involve community based-programs which prevent incarceration wherever 
possible and draw on traditional laws and cultural advantages, where appropriate, to deal with 
antisocial behaviours. Particular programs to assess risk, ensure support and if necessary treatment,
 are essential to prevent suicide deaths in custody.85 

Skills, knowledge and the attitude of police and correctional staff need to be 
addressed, as well as ensuring access to care and rehabilitation after release. 

Page 864 Mental Illness Inquiry 

In addition, it is essential to ensure that youth-oriented programs operate to 
assess and manage mental health problems or disorders from the earliest stages — to prevent
 young people entering the criminal justice system and provide 
alternative programs to imprisonment. This is likely to lessen the risk of 
chronicity, reoffending and mental illness resulting from imprisonment. 

Prevention and the Mental Health Care System 

As has been chronicled throughout this report, people who are at risk of or 
suffering from mental illness may be adversely affected by the system of care 
itself. The training and expertise of the professionals who care for them, the 
compassion and empathy with which they are assessed and treated, the quality 
and range of programs provided will all affect the extent to which their rights 
are respected. But our systems must, at a minimum, reflect policies and 
programs which ensure that they do not exacerbate mental illness and operate 
in the true traditions of care 'first not to harm'. 

Conclusion 

Prevention programs are not simple — but if carefully designed and appropriately 
resourced they have the capacity to prevent or significantly diminish the 
suffering associated with mental illness for many of those affected and their 
families. It is, therefore, essential that they become an integral part of our 
mental health care system. 

Human Rights and Equal Opportunity Commission Page 865 

1 N Sartorius and A S Henderson, 'The neglect of prevention in psychiatry', Australian and 
New Zealand Journal of Psychiatry, v26 No4, 1993, pp550-553. 
2 B Raphael, Scope for Prevention in Mental Health, National Health and Medical Research Council, 1993. 
3 D Nutbeam, M Wise, A Bauman, E Harris and S Leeder, Goals and targets for 
Australia's health in the year 2000 and beyond, Australian Government Printing Service, Canberra 1993. 
4 V Tippett and B Raphael, Goals and Targets for Australia's Health: Implication for Mental Health. 
Submitted for publication to the Australian and New Zealand Journal of Psychiatry, 1993. 
5 D and L Simpson, Great Lakes ARAFMI, NSW. Submission, p2. 
6 T Hatchett, consumer, South Australia. Oral evidence, Adelaide 21.10.91, pl53. 
7 M Bull, Vice President, NSW Association for Mental Health. Oral evidence, Sydney 16.6.91, p.292. 
8 A Deveson, Vice Chairperson and Dr M Leggatt, Secretary, Schizophrenia Australia Foundation. Submission, pi. 
9 G D Burrows, 'TAGS: Towards a gentler society', Mental Health in Australia, December 1989, pp25-26. 
10 L Mill, South Australia. Oral evidence, Adelaide 21.10.91, ppl31-2. 
11 B Graetz, 'Health consequences of employment and unemployment: Longitudinal evidence 
for young men and women', Social Science and Medicine, v36 No6, 1993, pp715-724. 
12 AH Winefield, M Tiggemann and R D Goldney, 'Psychological concomitants of 
satisfactory employment and unemployment in young people', Social Psychiatry and 
Psychiatric Epidemiology, v23 No3, 1988, ppl49-157. 
13 Australian Bureau of Statistics, Labour Force, Australian Government Printing Service, Canberra, 1993. 
14 Dr E Hunter, psychiatrist, Aboriginal Medical Service, Redfern. Oral evidence, Sydney 
21.6.91, p535. 
15 Aboriginal Medical Service, NSW Aboriginal Mental Health Report, Redfern 1991. 
16 R F Munoz, Y W Ying and R Armas, 'The San Francisco Depression Prevention 
Research Project: A randomised trial with medical outpatients'. In R F Munoz (ed), Depression 
prevention: Research Directions, New York 1986. 
17 Dr J Spencer et al, RANZCP, WA Branch. Submission, pi. 
18 See Chapter 3 — Definitions and Conceptions of Mental Illness and Chapter 24 — People from 
Non-English Speaking Background. 
19 Raphael, op cit. 
20 D Gordon, President, Australian Association of Social Workers, ACT. Submission, p4. 
21 Professor B Tonge, Head of Child Psychiatry, Royal Australian and New Zealand College of 
Psychiatrists; President, Australian Society of Adolescent Psychiatry; and Head of the Centre 
for Developmental Psychiatry, Monash University. Oral evidence, Melbourne 9.4.91 p236. 
22 M Rutter, 'Psychiatric Disorder in Patients as a Risk Factor for Children'. In D Shaffer,
 I Phillips and N B Enzer (eds), OSAP Prevention Monograph 2: Prevention of mental disorders,
 alcohol and other drug use in children and adolescents, US Department of Health and Human 
Services, Rockville 1989, ppl57-189. 

Page 866 Mental Illness Inquiry 

23 id. 
24 N Rae-Grant, 'Primary prevention: implications for the child psychiatrist', Canadian 
Journal of Psychiatry, 33, 1988, pp433-442. 
25 Raphael, op cit. 
26 Nutbeam et al, op cit. 
27 K Halford, 'Marriage and the prevention of psychiatric disorder', in B Raphael and G D Burrows
 (eds), Handbook of Preventive Psychiatry, (in press). 
28 B Barnett and G Parker, 'Professional and non-professional intervention for highly anxious
 primiparous mothers', British Journal of Psychiatry, vl46, 1985, pp287-293. 
29 B Raphael, 'Prevention of disorders of childhood and adolescence: Extent of childhood and 
adolescent psychiatric disorders'. In Scope for Prevention in Mental Health, National Health 
and Medical Research Council (in press). 
30 D Black, Inequalities in Health: Report of a research working group, Department of Health and
Social Security, London 1980. 
31 B L Bloom, W F Hodges and R A Caldwell, 'Preventive intervention program for the newly separated:
 Initial evaluation', American Journal of Community Psychology, vl0 No3, 1982, pp251-264. 
32 J D Gray, C A Cutler, J D Dean and C H Kemp, 'Prediction and prevention of child abuse and 
neglect', Journal of Social Issues, v35 No2, 1979, ppl27-139. 
33 Raphael, 'Prevention of disorders of childhood and adolescence...', op cit. 
34 E Deblinger, S V McLeer and D Henry, 'Cognitive behavioural treatment for sexually abused 
children suffering post-traumatic stress: Preliminary findings', Journal of the American Academy
 of Child and Adolescent Psychiatry, v29 No 5, 1990, pp747-752. 
35 C S Wisdom, 'Does Violence Beget Violence? A critical examination of the literature', 
Psychological Bulletin, vl06 Nol, 1989, pp3-28. 
36 B Raphael, 'Psychiatric aspects of preventive interventions with victims of violence'. In
 D Chappell, P Grabosky and H Strang (eds) Australian Violence: Contemporary Perspectives, 
Australian Institute of Criminology, Canberra 1991. 
37 D Chappell, P Grabosky and H Strang (eds), Australian Violence: Contemporary 
Perspectives, Australian Institute of Criminology, Canberra 1991. See also National Committee on
Violence, Violence: Directions for Australia, Australian Institute of Criminology, Canberra 1990. 
38 Raphael, Scope for Prevention in Mental Health, op cit. 
39 Rutter, op cit. 
40 J Lunz, President, Association of Child and Adolescent Mental Health Professionals. Second 
submission, pi. 
41 Raphael, 'Prevention of disorders of childhood and adolescence...', op cit. 
42 B Raphael, The Power of Youth, Paper presented to Rotary Conference, Canberra, 1992. 
43 A J Sameroff and B H Fiese, 'Conceptual issues in prevention', in Shaffer et al, op cit, pp23-53. 
44 Dr M Dudley, psychiatrist, Avoca Clinic Child and Adolescent Service, Prince of Wales Hospital,
 Sydney. Oral evidence, Sydney 18.6.91 pl99. 
45 D Shaffer, I Phillips, A Garland and K Bacon, 'Prevention issues in youth suicide', in Shaffer
 et al, op cit, pp373-412. 

Human Rights and Equal Opportunity Commission Page 867 

46 M Hibbert and Hibbert, Adolescent Health Survey 1992: Depression, Information Note No4, 
Centre for Adolescent Health, VicHealth, Melbourne, 1993. 
47 Depression Awareness, Recognition and Treatment Program — National Institute of Mental Health. 
48 M G Sawyer, A Sards, P A Baghurst, C A Cornish and R S Kalucy, 'The prevalence of emotional 
and behaviour disorders and patterns of service utilisation in children and adolescents', Australian
 and New Zealand Journal of Psychiatry, 24, pp323-330. 
49 Dr W Bor, psychiatrist representing the Faculty of Child Psychiatry, Queensland Branch, Royal
 Australian and New Zealand College of Psychiatrists. Oral evidence, Brisbane 15.8.91, pl599. 
50 D R Offord, 'Conduct Disorder: Risk Factors and Prevention', in Shaffer et al, op cit, pp273-307. 
51 J E Fleming and D R Offord, 'Epidemiology of childhood depressive disorders: A critical review',
 Journal of the American Academy of Child and Adolescent Psychiatry, v29 No4, 1990, pp571-580. 
52 M H Boyle, D R Offord, Y A Rancine and G Catlin, 'Ontario child health study follow-up: 
Evaluation of sample loss', Journal of the American Academy of Child and Adolescent Psychiatry,
 v30 No3, 1991, pp449-456. 
53 Sawyer et al, op cit. 
54 Nutbeam et al, op cit, pp81-90. 
55 L H Robins and R K Price, 'Adult disorders predicted by childhood conduct problems: Results
 from the NIMH epidemiologic catchment area project', Psychiatry, v54, ppll6 - 132. 
56 BR Matthews, K D Richardson, J Price and G Williams, 'Homeless youth and AIDS: Knowledge, 
attitudes and behaviour', Medical Journal of Australia, vl53 Nol, 1990, pp20-23. 
57 HREOC, Our Homeless Children, AGPS, Canberra 1989. 
58 M Bashir, personal communication. See generally Chapters 20 and 25. 
59 I R H Falloon, 'Early intervention for first episodes of Schizophrenia: A preliminary 
exploration', Psychiatry, v55, pp4-15. 
60 P McGorry, The RPMIP and the clarity and stability of the clinical picture in functional 
psychosis. PhD Thesis, Department of Psychological Medicine, Monash University, 1991. 
61 P McGorry, 'The concept of recovery and secondary prevention in psychotic disorders', 
Australian and New Zealand Journal of Psychiatry, v26, 1992, pp3-17. 
62 McGorry, 'The concept of recovery and secondary prevention in psychotic disorders', op cit. 
63 AC McFarlane, personal communication. 
64 E Howarth, J Johnson, G L Klerman and M Weissman, 'Depressive symptoms as relative and 
attributable risk factors for first-onset major depression', Archives of General Psychiatry, 
v49 Nol0, 1992, pp817-823. 
65 Program 'Defeating Depression' initiated by the Royal College of Psychiatrists. 
66 Depression Awareness, Recognition and Treatment, op cit. 
67 Raphael, 'Depression and related syndromes', in Scope for Prevention in Mental Health, op cit. 

Page 868 Mental Illness Inquiry 

68 W Rutz, J Walinder, G Eberhard, G Holmberg, A L von Knorring, L von Knorring, B Wistedt and A 
Aberg-Wistedt, 'An educational program on depressive disorders for general practitioners on Gotland:
 background and evaluation', Acta Psychiatrica Scandinavica, v79, 1989, ppl9-26. 
69 See also Chapter 26 — Mental Health Research 
70 A Reifman and Q J Wyatt, 'Lithium: A brake in the rising cost of mental illness', Archives of 
General Psychiatry, v37, 1980, pp385-388, estimated that in a ten year period the use of Lithium 
to prevent bipolar episodes saved (conservatively) $4 billion. 
71 Raphael, 'Prevention in relation to life stresses', in Scope for Prevention in Mental Health 
(Chapter on Life Events), op cit. 
72 Raphael, 'Depression and related syndromes', in Scope for Prevention in Mental Health, op cit. 
73 J Wilson and B Raphael, International Handbook of Traumatic Stress Syndromes, Plenum Press, 
New York, 1993. 
74 Raphael, 'Anxiety spectrum and related disorders', in Scope for Prevention in Mental Health, 
op cit. 
75 Raphael, 'Organic Syndromes', in Scope for Prevention in Mental Health, op cit. 
76 H Brodaty and D Hadzi-Pavlovic, 'Psychological effects on carers of living with persons with 
dementia', Australian and New Zealand Journal of Psychiatry, v24, 1991, pp351-361. 
77 Y Wells and A F Jorm, 'Evaluation of a special nursing home unit for dementia sufferers: A 
randomised controlled comparison with community care', Australian and New Zealand Journal of 
Psychiatry, v21 No4, 1987, pp524-531. 
78 I Gerber, R Rusalem and N Hannon, 'Anticipatory grief and aged widows and widowers', Journal
 of Gerontology, v30, 1975, pp225-229. 
79 Raphael, Scope for Prevention in Mental Health, op cit. 
80 id. 
81 G Roberts, J Lawrence, B O'Toole and G Raphael, Domestic Violence Research Project, 1992. 
82 BO Rothbaum, E B Foa, D S Riggs, T Murdock and W Walsh, 'A prospective 
examination of post traumatic stress disorder in rape victims', Journal of Traumatic Stress, 1991. 
83 E B Foa, B O Rothbaum, D S Riggs and T B Murdock, 'Treatment of post traumatic stress disorder 
in rape victims: A comparison between cognitive-behavioural procedures and counselling', 
Journal of Consulting and Clinical Psychology, v59 No5, 1991, pp715-723. 
84 Raphael, op cit. 
85 National Report: Royal Commission into Aboriginal Deaths in Custody, Canberra, 
Australian Government Publishing Service. 1991. 

Human Rights and Equal Opportunity Commission Page 869 

Chapter 28 

ACCOUNTABILITY 

Introduction 

There is an impressive array of statutory mechanisms to protect and maintain the
 human rights of people with mental illness in Victoria; yet there is still no 
doubt that their rights are still contravened, and that the channels of redress
are under-used by people with mental illness who have legitimate grievances about
these contraventions.1 

The human rights violations perpetrated in our three most populous States in 
relatively recent times — including those at Chelmsford Hospital in NSW, 
Ward 10B of Townsville Hospital in Queensland, Lakeside Hospital in Victoria 
and elsewhere — have demonstrated the urgent need for appropriate mechanisms 
to prevent such abuses and provide an effective means of intervening if 
they do occur. 

Inquiries which were set up to investigate these institutions and others have 
recommended fundamental changes. Recently there has been a great deal of 
activity, at both institutional and governmental levels, directed at achieving 
quality control in the delivery of mental health services. 

The National Mental Health Policy, launched by the Australian Health 
Ministers' Conference in May 1992, recognises the importance of developing 
national standards for mental health services and methods of assessing whether 
these standards are being met. The Policy also accords priority to the 
implementation of quality assurance programs; the development of protocols for 
clinical treatment by professional bodies; the accreditation of mental health 
facilities; and the development of nationally agreed measures of performance 
in relation to each of these areas. 

The way these commitments are to be implemented is detailed in the National 
Mental Health Plan. By endorsing the Plan (subject to Commonwealth financial 
contributions), State and Territory Health Ministers agreed to provide the 
information required to enable program monitoring; to establish national service 
standards; and to develop a strategy for nationally consistent mental health data. 

The establishment of effective controls and safeguards in the provision of 
psychiatric services is critically important. Because of the unique nature of 
these services it is also particularly problematic. Unlike other patients, mental 

Page 870 Mental Illness Inquiry 

health consumers may be deprived of their liberty. Even without involuntary 
detention, the identification of a person as mentally ill still has a profound 
impact on all aspects of their lives — in a way that diagnosis of most physical 
illness does not. Psychiatrists are perceived as more powerful than other 
doctors in that they deal with people's minds. 

Quality Assurance 

The term 'quality assurance' is sometimes used in a very general sense to cover 
most aspects of control and monitoring of the quality of services. For example, 
a submission to the Inquiry from the WA Branch of the Association of Social 
Workers defined the main components of quality assurance as: 

• professional supervision 
• performance management (both professional and administrative) 
• accountability 
• professional development 
• staff orientation 
• peer review 
• criteria audit 
• service review 
• statistics and data collection 
• specialist practice consultancy.2 
In other contexts the term is used to refer more specifically to the clinical 
process of peer review.3 However, the Inquiry found the most useful definition 
of quality assurance was that provided in the most recent edition of the 
Australian Council on Healthcare Standards (ACHS) Accreditation Guide: 

[Quality assurance is a] formal process whereby the quality and appropriateness 
of patient care and/or departmental performance is documented and evaluated by 
the professional group responsible or within a multi-disciplinary team. The process 
involves a planned and systematic approach to monitoring and assessing the care 
provided, or the service being delivered, which identifies opportunities for 
improvement and provides a mechanism through which action is taken to make and
 maintain improvements. There should be regular feedback of the results of quality 
assurance activities to the appropriate personnel.4 

Submissions to the Inquiry from State and Territory Governments indicated 
widespread support for quality assurance programs and activities — in 
principle. They did not, however, discuss the actual content of these programs 
in any detail. Although this can be partly attributed to the early stage of 
development of such programs, it also reflects the fact that responsibility for 

Human Rights and Equal Opportunity Commission Page 871 

developing programs and activities has been devolved to regional or even 
institutional levels. 

In Queensland, for example, in 1992 a quality assurance coordinator was 
appointed for each region. The coordinator (or coordinating committee) is 
responsible for identifying all services in the region and developing minimum 
service standards for each of them. 

In New South Wales, quality assurance activities are coordinated at an 
institutional level. According to its 1991-92 Annual Report, Rozelle Hospital, 
for example, has implemented a comprehensive series of quality assurance 
activities — ranging from a survey of ethnic access and review of medical 
prescriptions to an evaluation of boarding house accommodation services for 
people with mental illness in the Central Sydney Health Service and surveys of 
nursing activities and of occupational stress among psychiatric nurses. 

Over a decade ago, the Royal Australian and New Zealand College of Psychiatrists 
was funded by the Federal Department of Health (as it then was) to 
undertake the 'Quality Assurance Project'. This involved an extensive review 
of the relevant literature and consultation with practising psychiatrists and an 
expert committee. Detailed sets of criteria were developed for optimal 
individual clinical care in relation to each major psychiatric disorder. These 
comprehensive 'treatment outlines' were intended to be used in peer review 
processes and as sources of information, both for health planners and the wider 
community, concerning treatment options in current psychiatric practice. A 
discussion of the rationale and methodology of the Quality Assurance Project 
and the treatment outlines for each illness were published in a series of articles 
in the Australian and New Zealand Journal of Psychiatry between 1982 and 1985. 
The Inquiry was informed that the profession's involvement in the 
Project meant that the criteria were regarded as influential guidelines.5 

The Australian Council on Healthcare Standards, in revising its Accreditation 
Guide for use by health care facilities, included in its 6th edition (1988) a 
new standard for every category of health care facility. This standard (entitled 
'Quality Assurance Program') called for the monitoring and evaluation of both 
clinical and non-clinical activities. In the current edition of the ACHS guide, 
quality assurance, in addition to constituting one of the standards for each 
category of facility, is discussed at some length.6 The term is defined (see 
above), and the process of surveying the quality assurance standard is set out 
in some detail. 

Page 872 Mental Illness Inquiry 

Standards 

The quality of services can be measured in different ways. Both minimum and 
optimum standards are used — and varying degrees of prescription or sanction 
are attached to them. The most clearly prescriptive are those provided by 
legislation. Compliance with other standards, such as those laid down by the 
Australian Council on Health Care Standards, may be voluntary — but may still 
have significant consequences for funding or for issues such as attracting quality staff. 

Some of the most comprehensive standards for mental health services were 
published in 1991 by the NSW Department of Health a booklet entitled 
Standards of Care for Area Integrated Mental Health Services (AIMHS).7 
These standards were developed after consultation with experienced mental 
health professionals and representatives of consumer, family support and 
voluntary care organisations and they are expected to evolve to meet changing 
needs and circumstances.8 

Most importantly, they focus on outcomes for service users and care givers, 
moving from initial contact and assessment through to long-term follow up. 
They are designed for use, both by service providers and consumers, as a guide 
to the provision of quality services and as a check-list of the kinds of services that 
should be available at any particular stage of mental health care or treatment. 

Other initiatives have recently been taken to develop standards for mental health services 
— including several since the Inquiry was announced — by Federal, State and Territory 
governments, regional or area health administrations and voluntary bodies. 

In October 1991 the Chief Executive of the Northern Territory Department of 
Health and Community Services approved the Northern Territory Mental Health 
Care Standards, prepared by the Northern Territory's Mental Health Services 
Quality Assurance Committee after consultation with clinical staff throughout 
the Territory. These standards consist of general statements of principle 
(relating to matters such as organisation and administration, staffing, patient 
care, facilities and equipment, and quality assurance) accompanied by specific 
criteria describing who is to perform the initial assessment of patients; how this
 is to be recorded; and the way in which individualised treatment plans are to be 
documented. The criteria for these standards require monitoring, assessment, 
evaluation and feedback to staff as well as regular reports to senior manage-

Human Rights and Equal Opportunity Commission Page 873 

ment. There do not appear, however, to be any particular sanctions attached to 
non-compliance with these standards. 

In March 1990, the Mental Health Services Unit of the New South Wales 
Health Department published Guidelines for Psychiatric Inpatient Services, 
based on the resolutions from a seminar on quality assurance for inpatient 
services. Although compliance is not mandatory, the guidelines are 'strongly 
endorsed' by the Mental Health Services Unit. They set out the desirable 
standards in relation to matters such as the availability of psychiatric consultants
 and review procedures, monitoring of medication, handling and monitoring of ECT and 
the establishment of quality assurance committees. 

The Federal Department of Health, Housing, Local Government and 
Community Services has taken a more prescriptive approach by requiring 
nursing homes (since July 1987) and hostels (since January 1991) to comply 
with standards in areas including health care, social independence, freedom of 
choice, home-like environment, privacy and dignity, variety of experience and 
safety, as a condition of Commonwealth funding. Compliance is monitored by 
the Department and inadequate performance can result in the withdrawal of 
Commonwealth funding. 

The national service standards to be developed and introduced in accordance 
with the National Mental Health Plan, endorsed by the Health Ministers' 
Conference in April 1992, will presumably also be linked to funding. 

The Australian Council on Healthcare Standards provides an annually updated 
guide containing detailed standards for a wide range of specific health services,
 including, since the late 1980s, psychiatric services. While adherence to the ACHS 
standards is purely voluntary, they do form a basis on which facilities are surveyed 
for the purpose of accreditation. (The accreditation process is described in more 
detail below.) 

During the second half of 1992 a subcommittee of the Royal Australian and 
New Zealand College of Psychiatrists' Quality Assurance Committee, in 
conjunction with the ACHS Care Evaluation Program, began to field-test a 
range of clinical standards, referred to as Clinical Indicators for Psychiatry. 
The test, which is being conducted in fifteen hospitals around Australia, is 
designed to establish what data are required to facilitate the application of these 
indicators and whether they are acceptable to health providers as reasonable measures 
of their performance. Based on the results, the clinical indicators will be further 
modified before becoming a regular part of quality assurance processes in hospitals 
and the accreditation process used by the ACHS. 

Page 874 Mental Illness Inquiry 

Standards of psychiatric care are also governed by legislative criteria. The 
disparate mental health laws and regulations in each State contain a variety of 
provisions relating to the admission, treatment and discharge of patients or the 
procedures associated with involuntary detention that may be regarded as 
minimum standards. (These provisions are discussed in some detail in Chapter 
4 of this report.) 

Other relevant standards are prescribed in legislation relating to the administration of
 health services and the management of private hospital and health care facilities 
(in those jurisdictions where such legislation exists).9 

Following the exposure of abuses of patients' rights at Chelmsford Private 
Hospital, NSW enacted the Private Hospitals and Day Procedure Centres Act 
1988, establishing stringent provisions for the maintenance of standards at such 
facilities. The Act requires private hospitals and day procedure centres to be 
licensed, and specifies that standards for patient safety, care, quality of life and the
 quality and conduct of services may be prescribed by regulation. The 
Private Hospitals Regulation (NSW) 1990 contains detailed provisions in 
relation to staffing, facilities and equipment, record keeping, clinical standards, 
professional accountability and quality assurance procedures. Under this Regulation, 
each private hospital must also elect a medical advisory committee to advise the licensee 
in relation to the accreditation of practitioners providing services at the hospital 
and other matters concerning clinical practice or patient safety. 

Peer Review 

Everyone seems to be talking about peer review, but no one is able to say exactly what 
it means.10 

Peer review is a process involving assessments by clinical colleagues of one 
another's handling of cases. There are no universally accepted parameters. Nor 
is it clear what, if any, sanctions exist for clinicians who do not participate
 in such a process or for those whose handling of cases is found to fall below 
acceptable standards. Indeed, even the question of what standards are to apply 
will usually be a matter for agreement among the participants. 

Monitoring 

By the middle of this century the principle was established that the State was
 responsible for the maintenance of standards of medical and hospital practice
 in the community. There were commissions, boards, committees and other statutory 
bodies which had both the power and the duty to do so. This position had arisen
 partly because historically the 

Human Rights and Equal Opportunity Commission Page 875 

profession had shown no great enthusiasm for regulating itself and partly because 
it had no power to do so.11 

A number of mechanisms for inspecting and monitoring standards of care in 
psychiatric facilities have been discussed earlier in this report.12 In most
 States and Territories powers of inspection and investigation apply only to
 hospital facilities. In Victoria, however, they extend to all psychiatric
 services, including community support services, premises licensed for the
administration of ECT, general or private hospitals providing psychiatric treatment 
and any mental health service provided by a community health centre or psychiatric
 out patient clinic. 

In Victoria, a major monitoring exercise in the form of an Audit of Treatment 
and Care in Psychiatric Hospitals in the State of Victoria was announced by the 
Minister for Health shortly after the Inquiry began (in April 1991) — following 
an investigation into Lakeside Hospital. The audit, which reported in March 
1992, represents a major, one-off review of clinical practices and standards of 
patient care in all public psychiatric hospitals in Victoria. 

The audit was conducted by a team of five health professionals under the 
leadership of the Director of Psychiatric Services, assisted by ten senior 
academic psychiatrists. The team visited 19 hospitals, inspecting physical 
facilities, minutes of meetings, manuals of policies and procedures and patient 
case files; and interviewing managers, other staff and patients. 

The audit team found that although the State Office of Psychiatric Services had 
developed written standards for psychiatric nursing, rehabilitation, ECT and 
general inpatient services; and although quality assurance programs had begun 
in all but two of the hospitals surveyed, there were still major gaps. The team 
recommended that the Chief Psychiatrist develop written standards for the 
management and discharge of patients and for consultation and collaboration 
between clinical staff and patients, families and carers. 

Since the Inquiry began, Queensland has also instituted an audit of all 
psychiatric facilities, including private facilities, to which involuntary 
psychiatric patients may be admitted. The objective is to evaluate these services 
according to the requirements of its Mental Health Services Act and regulations. 
The Federal Department of Health, Housing, Local Government and 
Community Services has a Standards Monitoring Team, responsible for 
checking on compliance by hostels and nursing homes with the standards 
relating to health care, social independence, freedom of choice, privacy, 
dignity, variety of experience and safety. Action can be instigated for consistent
 non-compliance and Federal funding can be cut. 

Page 876 Mental Illness Inquiry 

Monitoring also forms part of the National Mental Health Plan launched in 
conjunction with the National Mental Health Policy in 1992. An annual system 
of reporting progress in implementation of the policy should commence in 
1993. The procedures and format are not yet clear. However, it is proposed 
that all State and Territory governments and the Commonwealth Government 
will provide 'agreed data', to be collated by the Commonwealth and published 
as a National Report on Mental Health. 

Accreditation 

It is my direct knowledge that a number of psychiatric catastrophes would not 
have occurred had accreditation been sought.13 

Accreditation is an evaluation process which accords formal recognition to an 
institution or individual that complies with defined standards of service and 
care. Clearly, the accrediting body must have some public standing and, 
preferably, independence. 

Australia's primary hospital accreditation body, the Australian Council on 
Healthcare Standards, was established in 1974 by the Australian Medical 
Association and the Australian Hospitals Association with the aim of improving 
quality of patient care in Australian hospitals. Since that time the Council's 
scope has expanded to include community health and day procedure facilities. 
Specific standards for psychiatric services were only developed in the late 
1980s. 

The process of accreditation by ACHS involves documentation of all services 
and programs. A survey is then conducted by a team of experts (usually 
including an administrator, a doctor and a nurse) which visits the facility and 
recommends to the Council whether it should be accredited. Facilities have a 
right of appeal against a refusal of accreditation. Accreditation may be granted 
for periods between one and five years. 

Community health centres may also seek accreditation by the Community 
Health Accreditation Standards Project (CHASP) which provides a comprehensive 
set of standards. Piloted in NSW and Queensland, and now operating 
on a national basis, this accreditation process is similar to that conducted by 
ACHS. 

Many witnesses, including one expert witness,14 suggested that psychiatric 
practice should be subject to more rigorous accreditation procedures. At present 
the Royal Australian and New Zealand College of Psychiatrists (RANZCP) 
provides a form of accreditation in that it confers fellowships on those medical 

Human Rights and Equal Opportunity Commission Page 877 

practitioners who satisfy prescribed standards of training and expertise. 
Advocates of accreditation argue that this should be extended (to cover areas 
of sub-specialisation, for example) and associated with a differential fee 
structure. This system could apply not simply to individual practitioners but to 
practices conducted by one or more psychiatrists at a given facility or location. 
(Other aspects of the training and continuing education of psychiatrists and 
other mental health professionals are dealt with in Chapter 6.) 

The RANZCP has recently reviewed its structure and processes to improve the 
profession's response to the accreditation of clinical standards.15 The College 
has upgraded its Clinical Standards Committee and established a new Quality 
Assurance Committee. These, together with the existing Ethics Committee and 
a newly formed Continuing Education Committee, will jointly constitute the 
Practice Standards Board.16 

The RANZCP published its first Code of Ethics after the Inquiry began — in 
August 1992. These are principles serving as a guide to good professional 
conduct — rather than clinical guidelines like the treatment outlines developed 
by the Quality Assurance Project. The principles deal with matters such as 
respect for 'the essential dignity and humanity of patients' and the need to 
obtain consent before undertaking any procedure or treatment. 

Professional Registration 

Medical practitioners, nurses and certain other health professionals are subject 
to statutory requirements of registration in each State and Territory and may be 
deregistered according to procedures laid down in the relevant legislation. The 
role that can be played by specialist bodies in bringing cases to the relevant 
professional disciplinary tribunals or even prosecuting alleged misconduct is 
discussed below under Complaints Mechanisms. 

Official Visitors 

The scheme of official visitors or community visitors has been addressed 
previously (see Chapter 4 — The Legal Framework and Chapter 8 — Inpatient 
Care and Treatment). Their functions and powers differ from State to State. In 
Victoria the scheme covers both general and psychiatric hospitals, and in NSW 
it extends to private psychiatric hospitals. In Queensland and Western Australia, 
however, official visitors are limited to public psychiatric hospitals. The other
 States and Territories have no statutory provision for official visitors. 

Page 878 Mental Illness Inquiry 

There is also a Community Visitors Scheme developed by the Federal Department of
 Health, Housing, Local Government and Community Services to monitor residents'
 rights in nursing homes and hostels that receive federal funds. 

Patient Rights and Patient Advocacy 

When you enter a psychiatric hospital you leave all your basic rights on the doorstep. 

In Victoria and the ACT legislative provision has been made for Government 
funded advocates to represent the interests of people with disabilities — 
although the fact that the Community Advocate Act in the ACT makes specific 
reference to representation for forensic patients has been interpreted as limiting 
the Community Advocate's functions in relation to people with mental illness generally.
 By contrast, the Office of the Public Advocate established under the Victorian Guardianship
 and Administration Board Act has established specialist mental health advocacy positions. 
The powers of the Victorian Public Advocate include representation or advocacy on behalf
 of people with disabilities and reporting on relevant recommendations to the Equal 
Opportunity Board. (However, as with other arrangements addressed in this chapter, 
the reality from a human rights standpoint is critically influenced not only by legislative
 prescription but by the resources which are actually available.) 

Advocacy is, importantly, also provided by community based and self-help 
groups funded (often inadequately) under Commonwealth and State Disability 
Services Acts. These groups mainly engage in lobbying, providing representation 
and support for individual clients and conducting community education 
programs. 

Since the Inquiry began, recognition of the rights of consumers and people in 
the community affected by mental illness has improved at several levels — if 
statements of rights and principles can be taken as any reliable guide. 

The ACHS Accreditation Guide now includes a statement of patients' rights and 
responsibilities. The Australian Health Ministers' Advisory Council adopted the 
Charter of Consumer Outcomes in March 1991 as the Mental Health Statement 
of Rights and Responsibilities. However, these have no direct sanctions 
attached. The Charters protecting the rights of residents in nursing homes and 
hostels (discussed in Chapter 17) are reflected in the standards by which the 
performance of these institutions is measured (see section above on Standards) 
and the National Service Standards for the Home and Community Care 
Program are based on the Statement of Rights and Responsibilities for HACC 

Human Rights and Equal Opportunity Commission Page 879 

consumers.18 The National Service Standards to be developed in accordance 
with the National Mental Health Plan will presumably be based on the Mental 
Health Statement of Rights and Responsibilities. 

In Victoria, NSW, South Australia, Queensland and, to a more limited extent, 
in the ACT, there are statutory requirements for statements of rights to be made 
available to those subject to involuntary detention. No such provisions exist in 
Western Australia, Tasmania and the Northern Territory. Evidence to the 
Inquiry clearly indicated, however, that even where they exist, statutory rights 
are not always observed in practice. 

The Queensland Health Rights Commission Act 1991 requires the Health Rights 
Commissioner, within three years of the commencement of the Act, to develop 
a Code of Health Rights and Responsibilities for consideration by the Minister. 
In developing this Code, the Commissioner is required to consult with the 
Health Advisory Council, consisting of representatives of the interests of 
service providers and users. 

In Western Australia, a Working Party commissioned by the Minister for 
Health to examine the rights and responsibilities of health care consumers 
proposed a Charter of Patients' Rights. This Draft Charter, published in 1991, 
has been a reference point in the process of drafting new mental health 
legislation in that state. The Western Australian Government has also involved 
consumer groups in planning, development and evaluation of policy and 
services. A Mental Health Interest Group forms part of the Health Advisory 
Network, which advises the Minister for Health, and a Consultative Forum for 
non-government organisations is intended to facilitate discussion of issues 
relating to consumers and non-government service providers. 

Prior to hearings conducted by the Inquiry, a statutory provision in the ACT 
for a Mental Health Advisory Council (consisting of representatives of nongovernment
 organisations, service providers and administrators) had been 
allowed to lapse because of difficulties in relation to the roles of different 
interest groups. In September 1992, however, the ACT Government announced 
the creation of a new Mental Health Advisory Council comprised entirely of 
representatives of mental health consumers and non-government carer 
organisations. 

Complaints Mechanisms 

Victoria and Queensland have independent statutory Commissioners with 
powers to investigate and conciliate complaints.19 In NSW, South Australia 

Page 880 Mental Illness Inquiry 

and the ACT there are specialist units established at an administrative level to 
handle complaints from consumers. 

Evidence to the Inquiry established that individuals who are, or have been, 
receiving treatment for mental illness may experience a number of perceived 
and real difficulties in accessing the processes of these professional disciplinary bodies.
 A solution to some, though by no means all, of these difficulties is provided in NSW by
 giving the Complaints Unit, established by the Health Department, power not only to 
investigate cases but also to prosecute them before the relevant professional body. 
The Victorian and Queensland Commissioners refer matters not resolved by conciliation 
to the relevant registration board without taking an adversarial role. 

However, Tasmania, Western Australia and the Northern Territory have no 
specialised mechanisms for handling complaints. This is a problem for several 
reasons. In addition to their role in handling individual complaints, specialist 
units perform an important function in monitoring the overall standards of 
service provided and identifying problem areas. 

In theory, it is open to anyone to bring an action in the courts for medical 
negligence, assault, battery, trespass to the person, false imprisonment or any 
other action recognised by law. In Tasmania the Mental Health Act 1963 actually imposes
a legal barrier to someone wanting to institute legal proceedings under that Act against 
a service provider, requiring leave of the Supreme Court before the action may proceed.20
While this provision is unique, it highlights the disadvantages that consumers of mental
 health services face more generally in pursuing legal action. They may, for some period
 of time, lack capacity to bring proceedings. However, even when capable, they may be
 faced with grave difficulties of proof in relation to prejudices about the 
credibility of their own evidence and that of others who might corroborate it. 
These problems are in addition to those that face any individual who contemplates legal 
action of any kind21 and, in particular, against a member of the medical profession. 

Conclusion 

There is, at least in theory, a plethora of controls and safeguards in the mental health
 area. However, there are no uniform, national guarantees of individuals' rights — nor
are there adequate mechanisms to ensure basic rights are properly protected. Recent
 initiatives include legislative measures as well as reforms of administrative and 
clinical practice. However, all these mechanisms require adequate resourcing if they
 are to operate effectively. 

Human Rights and Equal Opportunity Commission Page 881 

1. Dr Ian Siggins, (then) Health Services Commissioner, Victoria. Submission, pi. 
2. Maria Harries, President, Western Australia Branch of the Australian Association of
 Social Workers. Submission, p3. 
3. See, for example, the discussion of quality assurance, and in particular the quality 
assurance program at Northside Clinic, in Chapter 9 of the Honourable Mr Acting Justice 
JP Slattery's Report of the Royal Commission into Deep Sleep Therapy, Vol 13, Term 2, pp234-240. 
4. Australian Council on Healthcare Standards Accreditation Guide, 11th edition, pl2a. 
5. Dr John Ellard, Director, Northside Clinic. Oral evidence, Sydney 17.6.91, p72.
 Also see Professor Gavin Andrews, Professor of Psychiatry, University of NSW and 
Director of Health Services Research Group, Clinical Research Unit for Anxiety Disorders,
 St Vincent's Hospital, Sydney. Oral evidence, Sydney 17.6.91, p45. 
6. In the preamble to the standards. 
7. A Rosen, V Miller and G Parker, AIMHS Standards: Area Integrated Mental Health Standards
 Project, Sydney, 1990. 
8. id. 
9. See the analysis of Federal, State and Territory legislation contained in the Human Rights
 and Equal Opportunity Commission's Background Paper, Mental Health Legislation and Human
 Rights, December 1992. 
10. Dr Peter Wurth, letter to the editor, Australian and New Zealand Journal of Psychiatry,
 Vol 26, No 4, December 1992, p688. 
11. John Ellard, 'Chelmsford and After', Modern Medicine, August 1990, p87. 
12. See Chapter 4 — The Legal Framework. 
13. Ellard, 'Chelmsford and After', op cit, p92. 
14. ibid, pp91-93; also see Report of the Royal Commission into Deep Sleep Therapy, op cit, p236. 
15. Ellard, op cit, p95. 
16. id. 
17. Sara Hutchings, 'Hearing Users' Voices', Openmind, v41, Oct/Nov 1989, pl7. 
18. See Chapter 5 — Mental Health Services and Chapter 9 — Community Care and 
Treatment. 
19. See Chapter 4 - The Legal Framework. 
20. This point is examined in more detail in the Human Rights and Equal Opportunity 
Commission's Background Paper on Mental Health Legislation and Human Rights, op cit, p93. 
21. It has recently been estimated that the cost of pursuing an action in the District
 or County Court in most states now exceeds $40,000 and in the Supreme Court $60,000.
 This places litigation beyond the means of the vast majority of Australians affected 
by mental illness. 

Page 882 Mental Illness Inquiry 

Chapter 29 

LEGISLATIVE PROPOSALS 

Introduction 

In most jurisdictions mental health legislation has been under review during the 
course of the Inquiry, and in several States discussion papers or reports 
proposing reforms have been distributed. However, only South Australia and 
Western Australia have released draft bills. South Australia actually introduced 
its Mental Health Bill and Guardianship and Administration (Mental Capacity) 
Bill into the lower house in May 1992 — although these had not reached the 
second-reading stage at the time of writing. 

This analysis of proposed legislation1 does not include discussion papers or 
reports of legislative review committees or working parties. These, by 
definition, are liable to change in the processes of consultation and formulation
 of legislation. Moreover, it has been the experience of this Inquiry that discussion
 papers and other recommendations for reform of mental health 
legislation have frequently failed to produce tangible changes. Indeed, so low 
is the priority accorded to those affected by mental illness that even passage of 
legislation by Parliament has sometimes been ignored, or its effect postponed, by 
the Government of the day.2 

South Australia 

The South Australian Mental Health Bill 1992 does not represent a complete 
review of the existing Mental Health Act 1911. It is the result of changes 
arising from the separation of the guardianship provisions (dealt with later in 
this section in the context of the Guardianship and Administration Bill 1992 — 
together with a limited number of amendments to other provisions). 

The definition of mental illness remains unchanged — as do most of the criteria 
and procedures for involuntary detention. The statutory objectives are not 
significantly altered, apart from the removal of references to mental handicap 
and the inclusion of bodies such as the Guardianship Board, and individuals 
such as directors of approved treatment centres, among those responsible for 
observance of the objectives. A new position of Chief Adviser in Psychiatry is 
created by the Bill and provisions relating to the approval of hospitals are 
broadened to extend to treatment centres. 

Human Rights and Equal Opportunity Commission Page 883 

One new section expressly authorises the involuntary detention of patients 
admitted on a voluntary basis. The procedures for involuntary detention under 
the Bill allow for a second order for detention for 21 days before an order for 
continuing detention (for up to a year) is made. The criteria for continuing 
detention have been expanded. While the only express requirement under 
existing law is that further detention of an involuntary patient be considered 
necessary for the protection of others, the Bill requires, in addition, that the 
person continue to suffer mental illness and specifies that the patient's own 
interests may be considered as a criterion for continued detention. Otherwise, 
involuntary admission criteria are as in the current Act and fall short of the 
standards set by the UN Principles in that the terms 'in the interests of his or 
her safety' and 'for the protection of other persons' are very broad and there 
is no requirement that involuntary detention be the least restrictive alternative.3 

In contrast to the existing legislation, the Mental Health Bill contains explicit
 provisions governing administration of psychiatric treatment — distinguishing
 between cases in which it is permissible to treat without consent and those 
requiring informed consent. The Bill does not deal with the position of voluntary
 patients with respect to consent to treatment. 

The Bill also stipulates that patients detained for maximum periods of 3 or 21 
days, including those detained for a second period of 21 days, may be given 
treatment despite the absence or refusal of consent. (This does not include ECT 
or psychosurgery which, as in the existing Act, are subject to special 
constraints.) 

For patients detained for longer periods under continuing detention orders, the 
Bill requires that treatment be authorised by the Guardianship Board, except in 
cases where the nature of their mental illness is such that treatment is urgently
 needed for the protection of the individuals concerned or others; or where in the
 circumstances it is not practical to obtain authorisation. 

The Mental Health Bill makes limited changes to the existing powers of the 
police to apprehend individuals they believe to be suffering from mental illness. 

The only significant amendments relate to removing police powers to apprehend 
someone apparently suffering mental illness whose behaviour is such as to 
endanger life or property, and to break and enter premises using such force as 
is reasonably necessary. Powers retained in the Bill permit police to apprehend, 
with any reasonably necessary force, those believed to be suffering mental 
illness if their conduct is or has recently been such as to cause danger to 
themselves or others. 

Page 884 Mental Illness Inquiry 

The Bill abolishes the Mental Health Review Tribunal but gives enhanced rights 
of review to the Guardianship Board which, under the cognate Bill4, is 
reconstituted to include a specialist mental health division. This eliminates 
the existing overlap between these two bodies. The Bill also provides for review 
with fewer limitations than required by existing provisions — and with 
improved procedural safeguards. These include the right to representation 
before the Guardianship Board (at present only guaranteed in the Tribunal or 
Supreme Court) and an obligation on the Board to provide a written statement 
of the effect of any decision or order and rights of appeal. 

The Guardianship and Administration Bill reconstitutes the Guardianship Board 
and establishes a new office of the Public Advocate.5 The functions of the 
Public Advocate are: to keep under review programs provided in both the 
public and private sectors for 'mentally incapacitated persons'; to identify areas
 of unmet need and promote the development of programs; to speak for and 
promote the rights of 'mentally incapacitated persons'; to advise on rights under
 the Act and to monitor the administration of the Act. The Public Advocate may also 
act as guardian where there is no other suitable person.6 

In addition, the Bill confers on the Public Advocate duties and extensive 
coercive powers of investigation in cases where the Guardianship Board is 
likely to make orders for guardianship or administration of property. In the 
course of such investigations, the Advocate is empowered, after obtaining a 
warrant from the Board, to forcibly remove to a place approved by the Minister 
of Health anyone believed to have a mental incapacity who is being held against 
their will or treated in a manner likely to jeopardise their safety, health or 
welfare. 

Mental incapacity is defined in the Bill as inability to look after one's own 
health, safety or welfare as a result of either 'any damage to, or any illness, 
disorder, imperfect or delayed development, impairment or deterioration of the 
brain or mind' or 'any physical illness or condition that renders the person 
unable to communicate his or her intentions or wishes in any manner 
whatsoever'. 

The Bill specifies principles to be observed in its administration. These include
 according paramount consideration to what the decision maker considers would have
 been the person's wishes if it were not for their incapacity; and consideration and
 preservation of existing informal arrangements for their care. 

The proposed legislation also alters the constitution of the Guardianship Board. 
Provision is made for appointment of Deputy Presidents as well as the President 
and members. The Board is to comprise certain members who are to sit 

Human Rights and Equal Opportunity Commission Page 885 

exclusively in its jurisdiction under the mental health legislation. The Board is also empowered
 to appoint assistants for particular proceedings who are not to take part in the decision-making
process.7 

The Bill gives the Guardianship Board extensive powers to compel the 
production of evidence. There are also a number of procedural safeguards, 
including the right to reasonable notice, the right to call or give evidence, and the right
to representation (which may be by counsel, the Public Advocate or 
any other representative). However there is no guaranteed access to material for 
the purposes of presenting a case. 
The functions of the Board under the Bills8 combine those of the existing 
Guardianship Board and those of the existing Mental Health Review Tribunal. 
The provisions relating to the making of guardianship orders and orders for 
administration of property are more detailed and subject to far greater 
safeguards than at present. The Board may no longer receive a person into its 
own guardianship, but must appoint someone who cannot be a professional 
carer for the person concerned — unless there is good reason for such an 
appointment. 

The powers conferred on a guardian are to be limited and specified by the 
Board unless the Board is satisfied that 'full guardianship' is required. A special power 
is conferred on the Board, if satisfied that the health or safety of the protected person 
or the safety of others would be seriously at risk, to authorise detention of the person at
 a place of residence but not at a mental health treatment centre or correctional institution. 

The Board is required under the Bill initially to review guardianship orders 
after six months, then annually where a person is detained under an order of 
the Board, and at three yearly intervals in other cases. These review powers are 
in addition to those conferred by the Mental Health Bill in relation to detention under that 
Bill. 

There are provisions in the Guardianship and Administration Bill for appeals 
to the Administrative Appeals Division of the District Court (a relatively new 
Division) and to the Supreme Court. Such appeals are subject to fewer 
restrictions and greater safeguards than appeals from the Board to the Mental 
Health Review Tribunal under existing legislation. 

Potentially the most significant new development in the Bill is provision for a 
person to appoint an 'enduring guardian' by completing a form set out in a 
Schedule to the legislation. Such an appointment would come into effect only 
if and when the person subsequently becomes mentally incapacitated according 

Page 886 Mental Illness Inquiry 

to the definition in the legislation. The enduring guardian would have plenary 
guardianship powers subject to any conditions set out in the instrument of 
appointment. The Guardianship Board is given power to revoke the appointment 
of an enduring guardian but only where the guardian seeks revocation or the 
Board finds the enduring guardian unwilling or unsuitable to act in accordance 
with the principles set out in the legislation. There is no provision for review 
or revocation of enduring powers of guardianship on the ground that the 
'protected person' has regained capacity. 

The Guardianship and Administration Bill also contains innovative provisions 
enabling the Minister to introduce reciprocal arrangements with equivalent 
Ministers in any other State or Territory for the administration of guardianship 
or administration orders — provided the Minister is satisfied that the laws in 
the other jurisdiction correspond sufficiently to the South Australian provisions. 

Western Australia 

In December 1992, a draft Mental Health Bill was released for discussion by 
the Western Australian Minister for Health. This represents a complete revision 
of the Western Australian Mental Health Act 1962. The Bill contains, in 
simplified English, a number of reforms that would result in legislation more 
closely conforming to the goals set by the National Mental Health Policy than 
any existing legislation in Australia. In particular, it provides for specific civil 
and human rights of patients and makes major reforms in areas such as the 
criteria for detention, review of detention, and treatment in the community. 

The Bill contains a new definition of mental illness that is broad, but includes 
some relatively objective criteria.9 It also details the statutory objects (including
 the least restriction of freedom and least interference with the rights and dignity of
 people with mental illness), the functions of the Minister and the responsibilities of
 the Chief Psychiatrist. Among other functions, the Minister is required to consult with
 ethnic and other disadvantaged groups in the community to ensure that any special needs
 are understood and to ensure 
services for the treatment and care of people with mental illness are comprehensive, 
readily accessible and responsive to cultural diversity. 

The authorisation of hospitals for the treatment of involuntary psychiatric 
patients can, under the proposed Bill, be subject to criteria specified by 
regulation. There is also provision for the Commissioner for Health to negotiate 
funding and services agreements with registered community support services. 

Human Rights and Equal Opportunity Commission Page 887 

The criteria for involuntary detention are considerably tighter in the Bill than 
in the current Act. As in NSW, however, these criteria include the need for 
protection from serious financial harm, serious damage to reputation, or harm 
to personal relationships resulting from damage to reputation. The criteria are 
inconsistent with the standards set by the UN Principles for the Protection of 
Persons with Mental Illness in that they do not require that the harm be 
'immediate or imminent' or that there be a 'serious likelihood' of such harm.10 

Procedures for detention have also been tightened, requiring a medical 
practitioner who has personally examined the individual concerned to make a 
detailed written referral to a specific psychiatrist or place for examination. A 
person may only be made an involuntary patient after a psychiatric examination 
and only detained, initially, for up to 72 hours. If the person is to be detained any 
longer, they must be examined a second time. This examination may result in a further
period of detention for up to 21 days. Thereafter the involuntary status may be renewed 
for periods of up to 6 months on the basis of reexamination by a psychiatrist. The Bill 
requires the hospital administrator to 
ensure that each involuntary patient is examined by a psychiatrist at least once 
a month. There is also provision for automatic review by an independent body 
(a new Mental Health Review Tribunal — discussed below) within eight weeks. 
This also falls short of the standard set by the UN Principles — which require 
that initial detention be only for a 'short period' pending review by the 
independent body. In other respects, however, the detention procedures are 
generally consistent with the UN Principles. 

The Bill includes new provisions regarding the monitoring of treatment for 
patients in the community — both on leave from hospital and by way of 
alternatives to hospital. 

Where leave of absence is granted to an involuntary patient, the psychiatrist is 
required to assess the patient's continuing need for detention and their 
suitability for a Community Treatment Order. The provisions for Community 
Treatment Orders include the requirement that their use be considered as an 
alternative to detention each time a person is assessed for involuntary status. 
Community Treatment Orders may only be made by a psychiatrist who has 
examined the person and must be confirmed by a second psychiatrist or another 
doctor unless the person has been referred by a doctor under the provisions for 
involuntary admission. There are stringent criteria governing the form, 
duration, supervision and review of Community Treatment Orders. Failure to 
comply with a Community Treatment Order may result in admission as an 
involuntary patient. 

Page 888 Mental Illness Inquiry 

The Bill provides for continuing care orders for people who meet specified 
criteria — including having been an involuntary patient in the previous 18 
months and having refused treatment more than once or been unable, due to 
mental illness, to consent to treatment. These criteria also stipulate that an 
individual treatment plan must be implemented by a doctor or mental health 
practitioner who is qualified, willing and available to do so. As with community 
treatment orders, there are strict requirements for the imposition, duration, 
supervision and review of continuing care orders. Breach of the terms of an 
order may result in involuntary admission. 

One significant feature of the Bill, which is unique in mental health legislation in 
Australia and much needed, is a separate Part dealing with treatment and providing a
 detailed operational definition of informed consent. It also contains explicit
 provisions indicating when informed consent is required and when it is not. 

However, the Bill allows both involuntary and forensic patients to be given 
psychiatric treatment (other than certain prohibited or restricted treatments) 
without consent. There is provision for these patients to obtain a second opinion and 
where this opinion indicates modification or discontinuation of the 
treatment, the Chief Psychiatrist has a duty to make alternative arrangements. 
These provisions, however, are clearly inconsistent with the requirements of 
UN Principle 11 — which limits treatment without the patient's consent to cases 
in which an independent authority determines that the person either lacks 
capacity to consent or is unreasonably withholding consent and that a proposed 
plan of treatment is in the best interests of the person's health needs. 

The Bill also specifically authorises treatment without consent if it is 'emergency 
psychiatric treatment' (which is defined). Certain forms of treatment 
(deep sleep and insulin therapy) are banned outright and psychosurgery and 
ECT are subject to stringent controls (unlike the current legislation). 

Another unique and important feature of the Bill is a Part devoted entirely to 
the protection of patients' rights. These include the right to be informed of 
rights; the right of access to one's own hospital records (subject to a discretion
 to disclose only to a suitably qualified nominee of the patient); the right not to
 be ill-treated or neglected (with a $4000 fine or 2 years imprisonment for breach);
 the right to store and use articles for personal use; the right to correspond by 
post without interference; and the right to use the telephone in reasonable privacy.
 While there is provision for these rights to be restricted or denied by order of a
 psychiatrist, such an order lapses if not renewed in the course of a compulsory daily 
review. 

Human Rights and Equal Opportunity Commission Page 889 

Whereas the existing legislation omits provision for any specialist review body, 
the Bill creates both a Mental Health Review Tribunal and a Forensic Review 
Tribunal. 

The Mental Health Review Tribunal is to be constituted by three members, 
appointed by the Governor. They must include representatives of various 
special needs groups such as ethnic minorities and people in rural areas. They 
must also include at least one psychiatrist, one lawyer and one person who is 
not a member of the medical or legal professions. The Tribunal is required to 
automatically review all involuntary detention orders, Community Treatment 
Orders and Community Care Orders within eight weeks of their being made 
and at intervals not exceeding six months thereafter. Reviews may also be 
initiated by anyone considered to have a genuine concern. The Tribunal has the 
power to discharge involuntary patients, to place them on a Community Order, 
or to vary the terms of a Community Order. There is a right of appeal from the 
Tribunal to the Supreme Court on the basis of error of law, fact or jurisdiction. 

The Forensic Review Tribunal is similarly constituted — except that it must 
also include at least one Judge and one psychologist. This Tribunal also has the 
duty to automatically review orders for forensic patients, within eight weeks of 
the initial order and at not more than six monthly intervals. In addition, there 
is provision for automatic review by the Tribunal as near as possible to the time that 
a forensic patient would have been released if they had been convicted for the offence
 for which they had been brought before the court. There is also 
provision for reviews to be initiated by the patient, the Director of Public 
Prosecutions, the Chief Psychiatrist or anyone else with a genuine concern. 

Other functions of the Forensic Review Tribunal include the review of fitness 
to stand trial and the continuation of a patient's forensic status. The Bill sets out
 criteria for consideration by the Tribunal in determining whether or not a person 
should continue to be a forensic patient. The Tribunal has the power to discharge 
those who became forensic patients because of lack of capacity to understand criminal
 proceedings11 or because during a trial they were found to be of unsound mind12. 
However, in relation to those who have been 
acquitted of criminal charges on account of unsoundness of mind and ordered 
to be held in strict custody at the Governor's pleasure, the Tribunal may only 
recommend to the Minister for Health that the Governor be advised that the 
person should be released. 

Replacing existing provisions permitting police to apprehend individuals 
believed to be mentally ill, the Bill provides for apprehension by the police in 
more clearly defined circumstances and provides for the diversion of those 
apprehended from the criminal justice system to the mental health system. The 

Page 890 Mental Illness Inquiry 

police are given powers of entry (with necessary force), search and seizure (but 
the latter is limited to items likely to assist the medical examination of the 
person or items likely to be used by the person to prejudice their own or 
another's health or safety or to damage property.) 

The Bill contains innovative provisions enabling the Minister to make 
agreements with any other State or Territory to receive, care for, treat or deal 
with persons who come under the terms of the Western Australian legislation 
or to provide reciprocal services to individuals who are covered by the laws of 
other jurisdictions. 

The existing Boards of Visitors appointed to each psychiatric hospital would be 
replaced under the Bill by one larger Board covering all involuntary and 
forensic patients and those under continuing care orders. The members, 
appointed by the Minister, are to be known as official visitors — whose 
functions are broader than those of the current Boards. Under the proposed 
arrangements official visitors must ensure that people are informed of their 
rights and must assist in the making and presentation of applications or appeals 
under the legislation. 

Conclusion 

While the provisions of the proposed legislation in both SA and WA are not 
entirely consistent with the UN Principles, the proposals, and the Western 
Australian Bill in particular, constitute major improvements on existing 
legislative provisions. They also acknowledge the necessity for effective 
arrangements between different jurisdictions with respect to the treatments of 
those affected by mental illness. It must be emphasised, however, that in both 
States, at the time of writing, this legislation is not in effect. Both States should
 move to accord its passage the highest priority. 

Human Rights and Equal Opportunity Commission Page 891 

1 This chapter, like the previous one, should be read in conjunction with the Commission's 
Background Paper Mental Health Legislation and Human Rights: An Analysis of Australian Mental
 Health Legislation in Terms of the UN Principles for the Protection of Persons with Mental
 Illness, AGPS, December 1992. 
2 Western Australia has been reviewing its mental health legislation for well over a decade
 and even passed a new Mental Health Act in 1991 without ever proclaiming it. In NSW, debate
 for many years over reform of the Mental Health Act 1958 lead to passage of the Mental Health
 Act 1983 which was only partially proclaimed at different times during the next seven years.
 It was eventually replaced by the Mental Health Act 1990. In the ACT, the Mental Health Review
 Committee's report - Balancing Rights - was published in 1990 but has not yet produced any 
significant changes to the mental health legislation - although 
there has been separate legislation establishing a Community Advocate and Guardianship and 
Management of Property Tribunal. 
3 See Principles 9 and 16, Principles For The Protection Of Persons With Mental Illness And For
 The Improvement Of Mental Health Care, at Appendix 5. 
4 The Guardianship and Administration (Mental Capacity) Bill 1992. 
5 The Public Advocate is to be appointed by the Governor for a term of five years and may only 
be removed from office by the Governor on specific grounds. 
6 The Minister may also assign additional functions to the Public Advocate. 
7 This is to allow specialist advisers or people with specialist expertise to assist the Board 
in reaching appropriate decisions. 
8 Mental Health Bill 1992 and Guardianship and Administration (Mental Capacity) Bill 1992 
9 'a disturbance of thought, mood, volition, perception, orientation or memory that impairs 
judgement to a significant extent' (clause 3(2)). 
10 See Principle 16, Principles For The Protection Of Persons With Mental Illness And For
 The Improvement Of Mental Health Care, at Appendix C. 
11 Under section 631 of the WA Criminal Code. 
12 ibid, section 652. 

Page 892 Mental Illness Inquiry 

Part V 

Findings and Recommendations 

Chapter 30 

LEGISLATION: FINDINGS AND RECOMMENDATIONS 


In its background paper — Mental Health Legislation and Human Rights — 
published in December 1992, the Inquiry analysed mental health laws in each 
State and Territory in terms of the UN Principles for the Protection of Persons 
with Mental Illness and for the Improvement of Mental Health Care (see 
Appendix 5). Widespread breaches of the standards prescribed by those 
Principles were identified in the background paper. The findings and recommendations
 set out in this chapter address the problems identified and the 
concerns raised in evidence to the Inquiry. 

One fundamental problem is the language of most existing laws; both the form 
and substance of the legislation work against the assertion of rights by people 
with mental illness. The ACT still relies (in relation to forensic patients) on 
legislation from last century which uses the terms 'lunacy' and 'insane'. In a 
number of jurisdictions the criminal law still refers to 'insanity' — long after 
such terminology has been abandoned in the civil sphere. These pejorative 
terms perpetuate the stigma associated with mental illness. Moreover, the way 
in which mental health legislation is written, particularly in Queensland and 
Tasmania, makes it difficult to comprehend — even for those with legal 
training. The drafting style is turgid, the structure hard to follow and there is
 insufficient use of clear headings as 'signposts'. Such laws are not well suited 
to use in emergency situations; nor do they help service providers or consumers to
 appreciate or to enforce the rights that the laws confer. Mental health legislation
 must be expressed in clear and accessible terms and provide 
procedures that are as simple as possible — especially for emergencies. 

The findings and recommendations set out in this chapter relate specifically to 
changes which should be accorded priority by governments in amending or 
introducing mental health or related legislation. They should be read in 
conjunction with the findings and recommendations set out in Chapter 31 — 
which deal more generally with reforms which are necessary to policies, 
programs and services to ensure proper protection of the rights of Australians 
affected by mental illness. 

Human Rights and Equal Opportunity Commission Page 895 

STATE LEGISLATION 

In our view, mental health legislation should start with the principle that it
 is an extremely serious matter to deprive a person of his liberty. Allowing for that, 
it should allow for prompt, effective action to provide for the care and control of 
someone who has become acutely disturbed, allowing them to be taken to a place of 
safety and evaluated. It should provide some means of protecting those who have
 become mentally incompetent and it should provide effective means by which individual
 rights are protected and the actions of those who are placed in control of people who
 have become incompetent become accountable and able to be monitored. The current 
legislation fails rather dismally by any test.1 

Statutory Objects and Definitions 

Findings: 

• Certain jurisdictions (the Northern Territory and Western Australia) have no 
statements of principles or objectives in their mental health legislation. Laws 
in other jurisdictions are inadequate in that they give insufficient emphasis to 
the principle of the 'least restrictive alternative' in relation to the care and 
treatment of people with mental illness. 
• In most jurisdictions mental illness is not defined at all in existing mental 
health legislation — or is defined in a way that is inadequate in light of modern knowledge.
 This creates uncertainty over issues that are critical to matters of admission, treatment 
and discharge. It also provides no basis for consistency among and between Australia's eight
 different jurisdictions. 

Recommendations: 

• Mental health legislation should clearly set out the principles and objects 
on which it is based and, in particular, should give emphasis to the 
principle of the least restrictive form of appropriate care and treatment. 
• There should be a clear and consistent definition of mental illness in 
each jurisdiction's mental health Act, providing specific criteria which 
apply in all jurisdictions. 

Voluntary Admission 

The situation which gave rise to the criminal charge occurred shortly after her fifth 
[unsuccessful] attempt to admit herself as a voluntary patient.. ? 

Page 896 Mental Illness Inquiry 


Findings: 

• Mental health legislation makes insufficient provision for the rights of 
voluntary (or informal) patients. 
• Most jurisdictions do not provide a right of appeal against refusal of 
admission as an informal patient. 
• The rights of informal patients to discharge themselves are often subject to 
significant restrictions, and no legislation clearly deals with the rights of 
voluntary patients to refuse specific forms of treatment. 

Recommendations : 

• Provision should be made for a right to appeal against refusal to admit 
an individual as a voluntary patient. 
• The right of voluntary patients to discharge themselves should not be 
limited other than to provide sufficient notice to allow urgent action to 
detain them if this is justifiable under the provisions for involuntary 
treatment. 
• There should be a clear statement concerning the extent of the rights of 
voluntary patients to refuse specific forms of treatment. 

Involuntary Admission 

There are certainly some members of the medical profession who regard the processes 
and procedures for detaining people in... a cavalier fashion.3 

Findings: 

• The criteria for detention are too broadly defined in most jurisdictions. 
• The procedures for involuntary admission in a number of States involve the 
exercise by police, magistrates and medical practitioners of very wide 
discretion. 
• In most jurisdictions there is insufficient provision for assessment by 
appropriately independent and expert medical practitioners prior to detention. 
• Detention procedures in emergencies are often inappropriately cumbersome. 

Human Rights and Equal Opportunity Commission Page 897 

Recommendations: 

The criteria and procedures for detention in emergencies should be clear 
and clearly specified. Limits on their application should be clearly defined. 

The criteria for involuntary admission should be specific and should include
 the requirement that there is no less restrictive form of appropriate treatment available. 

Procedures for involuntary admission should require assessment by independent
expert medical practitioners. (In emergencies the initial opinion of more 
generally qualified health practitioners must be verified or varied by an 
appropriately qualified expert as quickly as possible.) 

Review 

In the area of civil commitment of the mentally ill we vest great power in the
 hands of medical practitioners. No matter how well-intentioned, how humane these
 people may be, I suggest that it's axiomatic that their daily practices have to
 be subject to proper external review.4

Findings: 

• Provisions for review are non-existent or inadequate in a number of 
jurisdictions. 
• Where independent review bodies exist, they are not always required to 
automatically review patients. 
• The intervals for which a person may be detained without review are frequently 
excessive (many patients are discharged before the statutory time for review has elapsed). 

Recommendations: 

• Independent specialist review bodies should be established in every jurisdiction. 
• These review bodies should be required to conduct an initial review of 
involuntary patients within a time limit that is less than the average term of detention. 

Page 898 Mental Illness Inquiry 

• These review bodies should also be required to review involuntary patients at
 intervals of no more than six months and voluntary patients at intervals no longer than 
one year. 
• Individuals should be guaranteed a right to apply to the review body for 
discharge — exercisable by either the person concerned or an authorised 
relative or friend of the patient. 

Procedural Safeguards 

A person finds themselves going into a hearing with or without a lawyer, with a
 state system, a hospital system, which has for ten years been building a case
 against them... There are clinical files, there are all sorts of diagnoses, 
labelling, and systems which the psychiatric consumer may in part be familiar
 with and yet for the most part they will be entirely unaware of... The individual 
is very poorly resourced to deal with the legal proceedings which are taking place.5 

Findings: 

• Few jurisdictions make statutory provision for personal appearance or legal 
representation at review hearings. 
• In no jurisdiction is there express provision for access to an interpreter. 
• Where legislative provision is made for access to information relevant to a 
case under review, this is not done in sufficiently clear, straightforward terms. 

Recommendations: 

• Individuals should be given statutory rights to appear in person at 
review hearings, to have access to an interpreter if necessary, and to be 
represented by a lawyer or other person with leave of the tribunal. 
• Provision should expressly be made guaranteeing the basic elements of 
natural justice — in particular, access to relevant information. 
• Individuals should have a right of appeal from decisions of the review 
body. 

Human Rights and Equal Opportunity Commission Page 899 

Treatment 

I don't think that medical culture has yet embraced the notion that patients have 
rights and that people must be seen as more than simply diagnostic labels 
and vehicles for treatment.6 

Findings: 

• Few jurisdictions provide for involuntary treatment without detention. 
• While some jurisdictions have detailed requirements for administration of 
ECT and psychosurgery, others have none. 
• In all jurisdictions there is inadequate clarity in legislation relating to the
 requirements for informed consent to general psychiatric treatment of voluntary 
and involuntary patients. 

Recommendations: 

• Legislation in all jurisdictions should make provision for compulsory 
treatment in the community. Appropriate safeguards must be prescribed to avoid 
over-use or other forms of abuse. 
• Administration of ECT or psychosurgery (where it is permitted) must be subject to 
stringent and clearly specified requirements for consent by the patient, where this
 is possible, and independent specialist approval. 
• The position of voluntary and involuntary patients regarding consent to 
general psychiatric treatment must be set out clearly in legislation. 

Confidentiality 

Finding: 

• Safeguards against breaches of confidentiality in the mental health system are 
inadequate. 

Recommendation: 

• Every jurisdiction should have penalties for breaches of confidentiality 
in relation to personal information obtained in the administration of mental health
legislation. 

Page 900 Mental Illness Inquiry 

Forensic Patients 

Release decisions are made by State Cabinet and, inevitably, it appears political 
considerations are taken into account.7 

Findings: 

• Most jurisdictions do not adequately divert from the criminal justice system 
individuals accused of crimes who require psychiatric treatment. 
• In most jurisdictions patients accused or convicted of a criminal offence have 
lesser rights in relation to matters such as treatment, information, and review 
than other patients. 
• In most jurisdictions, decisions to discharge forensic patients are not made by
 an independent review body. 

Recommendations:8 

• Mental health and related legislation must ensure that any person accused or
 convicted of criminal offences and in need of psychiatric treatment is provided
 with such treatment in an appropriate environment. 
• Forensic patients should be accorded rights equivalent to those of other 
patients in matters other than leave and discharge. 
• Decisions about the discharge of forensic patients should be made by an 
independent body and not at a political level. 

Legislative Controls 

What we really need is an ongoing whistle blower which is independent...and which
 will be able to go around and constantly bring to public attention any difficulties
 in standards, in particular, in hospitals.9 

Findings: 

• While all mental health legislation provides for safeguards and standards in 
hospitals designated for the involuntary treatment of mental illness, there is
 not the same systematic control in relation to community treatment facilities. 

Human Rights and Equal Opportunity Commission Page 901 

• There is, in most jurisdictions, a paucity or complete absence of criteria for 
monitoring standards in psychiatric facilities. 
• Most jurisdictions do not have a statutory mechanism for consumer complaints. 
• Most jurisdictions do not have an independent advocate monitoring conditions 
of treatment. 

Recommendations: 

• Legislation should set out clear criteria for the approval of all psychiatric 
facilities. It is also recommended that the Commonwealth adopt a monitoring
 role in this regard. 
• Safeguards and controls applicable to compulsory treatment by community
 facilities should ensure rights at least equivalent to those specified in 
relation to designated hospitals. 
• Consumer complaints should be dealt with by a statutory body with appropriate
 powers to investigate and either to settle by conciliation or to 'prosecute' 
where appropriate. 
• Each State and Territory should have an independent advocate with statutory 
power and responsibility to monitor the provision of services and maintenance of standards. 

Guardianship and Administration 

Findings: 

• In some jurisdictions there are no provisions for an independent determination 
concerning the capacity of individuals with mental illness to make decisions 
regarding their personal and financial affairs and for appointment of substitute 
decision-makers. 
• While several jurisdictions have provision for enduring powers of attorney, 
there is not similar provision for self-determination and planning of guardianship. 

Page 902 Mental Illness Inquiry 

Recommendations: 

• Every State and Territory should have an independent statutory body with power to determine
 capacity in relation to personal and financial affairs and to appoint substitute decision-makers
 where appropriate. 
• Every jurisdiction should make provision for individuals to appoint a nominee to be their 
guardian and to specify the conditions they wish to place on such guardianship while they 
have the capacity to do so. 

Anti-Discrimination 

Finding: 

• In some jurisdictions there is no prohibition in State or Territory legislation 
(as compared to Federal legislation) against discrimination on the ground of mental
 illness or psychiatric disability. 

Recommendation: 

• Discrimination (appropriately defined) on the ground of mental illness 
or psychiatric disability should be proscribed by law in every jurisdiction. 

Inter-State Co-operation 

We have eight different jurisdictions and some really very bizarre situations arise...
 For example...patients from the Northern Territory — the Alice Springs areas — 
were often moved to South Australia for treatment and you would have a fairly 
strange situation occurring at Adelaide airport where the Territory authorities 
would formally hand over to the South Australian authorities and the individual
 would have to be re-certified. It was like something from a spy novel, a transfer
 at the Berlin Wall.10 

Finding: 

• Serious difficulties are caused by governments' limiting of recognition of 
orders and provisions under mental health, guardianship and administration 
legislation to their own States or Territories. Many individuals affected by 
mental illness are highly mobile and indeed are sometimes transferred across 
State borders for treatment. 

Human Rights and Equal Opportunity Commission Page 903 

Recommendation: 

Every jurisdiction should have legislative provision for the reciprocal 
recognition of orders relating to detention, involuntary treatment, guardianship 
and administration of property. 

FEDERAL LEGISLATION 

Finding: 

• The definition of 'hostel' in the Aged or Disabled Persons Care Act 
specifically excludes an institution exclusively or primarily for people with 
mental illness and receiving funding from a State government. 

Recommendation: 

• This exclusion should be removed so that the Federal government can fund hostels
 conducted for people with mental illness regardless of whether the institution also
 receives some State funding. 
Finding: 

• The criteria in Regulations under the Aged or Disabled Persons Care Act 
governing eligibility for hostel care (in hostels funded under that Act) 
discriminate against people affected by mental illness. 
Recommendation: 

• The criteria governing eligibility for care in federally funded hostels 
should be amended to ensure they do not discriminate against those affected by mental illness. 

Finding: 

• Criteria under the National Health Act for classification of residents of 
nursing homes according to the level of personal care they require, do not give 
sufficient weight to cognitive and/or affective dysfunction. Similar deficiencies 
exist in relation to criteria governing eligibility for the Domiciliary Nursing Care Benefit. 

Page 904 Mental Illness Inquiry 

Recommendation: 

• These criteria should be amended to give greater weight to the personal care needs
 of those with cognitive and/or affective dysfunction. 

Finding: 

• The limitation of eligibility for the Domiciliary Nursing Care Benefit under 
the National Health Act to carers who reside in the same homes as those for whom they
 care is unduly restrictive. 

Recommendation: 

• Eligibility for the Domiciliary Nursing Care Benefit under the National Health Act
 should be extended to carers who live separately from those for whom they care,
 provided this care is sufficiently intensive and regular. 

Finding: 

• The procedures for obtaining and maintaining eligibility for Disability 
Pension, Sickness Allowance and Job Search and Newstart Benefits include 
requirements which are often difficult for people with mental illness to meet. 

Recommendation: 

• Procedural requirements for these Pensions, Allowances and Benefits should be made
 sufficiently flexible to take account of difficulties that may be encountered in
 relation to matters such as accommodation and the intermittent nature of much psychiatric 
disability. 

Finding: 

• The criteria for psychiatric impairment under the Social Security (Disability 
and Sickness Support) Amendment Act are too vague and, in particular, lack 
specificity as to the frequency of symptoms required. 

Recommendation: 

• These criteria should be amended to make them clearer and more specific. 

Human Rights and Equal Opportunity Commission Page 905 

Finding: 

• The categories of service for which rebates are available under the Health 
Insurance Act do not cover many 'non-medical' services, such as psychological 
counselling and stress management, which can be particularly important in 
preventing mental illness or its recurrence, or promoting effective rehabilitation of 
those affected. 

Recommendation: 

• The Federal Government should include a broader range of options within the scope of services
 for which rebates are available — particularly for psychological and counselling services
 which are important to those affected by mental illness. 

Page 906 Mental Illness Inquiry 

1. Dr Ian Sale, Tasmanian Branch, RANZCP. Oral evidence, Hobart 12.11.91, pl87. 
2. Karen Fryar, ACT Legal Aid Office. Oral evidence, Canberra 18.3.92, p74. 
3. Keith Darwin, community representative on the SA Mental Health Review Tribunal. Oral evidence,
 Adelaide 23.10.91, p382. 
4. Neil Rees, President, Victorian Mental Health Review Board. Oral evidence, Melbourne 8.4.91, p21. 
5. Steven Hird, solicitor, Mental Health Legal Service. Oral evidence, Melbourne 10.4.91, p427. 
6. Rees, op cit, p21. 
7. ibid, p26. 
8. More details relevant to several of these recommendations are provided in Chapter 31. 
9. Rees, op cit, p25. 
10. Sale, op cit, pl93. 

Human Rights and Equal Opportunity Commission Page 907 

Chapter 31 

GENERAL FINDINGS AND RECOMMENDATIONS 

General Conclusions 

• People affected by mental illness are among the most vulnerable and 
disadvantaged in our community. They suffer from widespread, systemic discrimination
 and are consistently denied the rights and services to which they 
are entitled. 
• Individuals with special needs — children and adolescents, the elderly, the 
homeless, women, Aboriginal and Torres Strait Islander people, people from 
non-English speaking backgrounds, those with dual or multiple disabilities, 
people in rural and isolated areas and prisoners — bear the burden of double 
disadvantage and seriously inadequate specialist services. 
• The level of ignorance and discrimination still associated with mental illness 
and psychiatric disability in the 1990s is completely unacceptable and must be 
addressed. 
• In general, the savings resulting from deinstitutionalisation have not been 
redirected to mental health services in the community. These remain seriously 
underfunded, as do the non-government organisations which struggle to support 
consumers and their carers. While the movement towards mainstreaming mental 
health services may alleviate the stigma associated with psychiatric care, there 
is a serious risk it will not receive the resources it so desperately needs. 
• Poor inter-sectoral links, the ambivalent stance of the private sector and a 
reluctance on the part of government agencies to co-operate in the delivery of 
services to people with mental illness have contributed to the alarming situation 
described in this report. While the Inquiry welcomes the initiative recently taken
 by governments in endorsing a National Mental Health Policy and Plan, a major 
injection of resources will be needed before we are in a position to comply with 
our international obligations under the UN Principles for the 
Protection of Persons with Mental Illness. 

Page 908 Mental Illness Inquiry 

Mental Health Services (Chapter 5) 

Findings: 

• The promise of more, and more effective, community-based services following 
implementation of policies of deinstitutionalisation has not been realised. Most
 jurisdictions have not substantially redirected funds from expensive inpatient
 psychiatric institutions to community mental health services. 
• New policies of 'mainstreaming' mental health services will not work without 
a substantial increase in resources and greatly improved coordination between 
all government and non-government service providers. 
• Concerns about mainstreaming are particularly pronounced in relation to 
specialist services. Specialist public and private mental heath services in 
Australia are inadequate and underfunded; there is a real risk that they will be 
increasingly marginalised. 
• Many psychiatrists in private practice treat few people affected by serious 
mental illnesses. 
• The existing relationship between the public and private psychiatric systems 
militates against optimum patient care. 
• Private inpatient care is virtually unobtainable by people who do not have 
private health insurance. There is also evidence that certain funds may 
discriminate against people with mental illness. 
• Although levels of funding suggest that the non-government sector is regarded 
as peripheral to psychiatric treatment and rehabilitation, governments are 
deliberately relying increasingly on non-government organisations (NGOs). 
Indeed, evidence to the Inquiry indicated that NGOs are now assisting many 
people virtually discarded as 'untreatable' by the public psychiatric system. 

Recommendations: 

• Federal, State and Territory governments should provide increased 
funding and resources to integrated mental health services as a matter 
of urgency. In the first instance Governments must give priority to 
redirecting funding from high cost institutions to such services. 
• Governments should accord a high priority to improving inter-agency 
and inter-sectoral co-operation and coordination. 

Human Rights and Equal Opportunity Commission Page 909 

Governments should investigate innovative methods of service provision in
 consultation with non-government organisations and the private health sector. 
The possibility of leasing beds from the private sector to cater for people with 
special needs (such as children and adolescents) should be pursued in some areas. 

• Private psychiatrists should acknowledge a professional responsibility 
to treat serious mental illness. 
• Links between the public and private psychiatric systems must be 
strengthened and particular attention given to access by private 
psychiatrists to the public system. 
• Private health funds should ensure eligibility criteria are nondiscriminatory. 
• All governments must substantially increase funding and resources to 
non-government services. 
• Federal, State and Territory governments should improve access to 
relevant non-psychiatric programs and services such as HACC, SAAP 
and public housing programs. 
Governments should encourage the establishment of non-government 
services in rural and isolated areas. 

Health Professionals (Chapter 6) 

Findings: 

• The quality of psychiatric care is critical to the welfare of many individuals 
affected by mental illness. 
• Medicare funding is not available for a wide range of services provided in the 
community. 
• The continuing drift of mental health professionals and allied staff from the 
public sector to the private sector is seriously restricting access by people with 
mental illness to appropriate services. 
• The needs of mental health professionals and allied staff in terms of primary 
and continuing education and training are not adequately met. 

Page 910 Mental Illness Inquiry 

• General practitioners (GPs) have insufficient training in the assessment and 
treatment of mental illness. This is particularly apparent in specialised areas 
such as the diagnosis and treatment of psychiatric disorders and mental health 
problems in the elderly, children and adolescents and other particularly 
vulnerable groups. 
• Mental health professionals and allied staff working both in institutions and 
the community require education and training in the delivery of community-
based services. 
• Workers and service providers in other sectors need appropriate training and 
education to meet the specific needs of people with mental illness. 

Recommendations: 

• The Federal Government, in consultation with State and Territory Governments, 
service providers, mental health professionals and allied staff, and people with
 mental illness should develop and implement national standards concerning the 
regulation and maintenance of psychiatric care and treatment. These standards 
should, inter alia, address the issue of appropriate minimum staffing levels to 
ensure effective treatment. 
• The Federal Government, in consultation with State and Territory Governments 
and service providers should examine and clarify the treatment roles of mental 
health professionals and allied staff working both in institutions and in the 
community. In particular, the roles of psychiatrists and clinical psychologists 
should be carefully assessed to ensure the most effective utilisation of professional 
services. 
• The role of mental health professionals and allied staff in the delivery of
 community-based services must be adequately recognised by the Federal government
 in Medicare funding. 
• The Federal Government, in consultation with State and Territory Governments,
 service providers, professional associations, mental health professionals and 
allied staff should examine options to encourage mental health professionals
 and allied staff to work in the public sector. Options for expanding the role 
of mental health professionals and allied staff in the private sector in the 
treatment of people with chronic mental illness should also be examined. 

Human Rights and Equal Opportunity Commission Page 911 

• The Federal Government, in consultation with State and Territory 
Governments and professional associations should improve the links 
between GPs and private and public sector mental health professionals 
and allied staff. Consultation-liaison psychiatry should be supported. 
• Education authorities should examine the mental health education and 
training system in order to identify deficiencies and clearly define the 
specific training needs of mental health professionals and allied staff 
working with people with mental illness 
• Major universities should be encouraged to make academic appointments 
in rehabilitation psychiatry and psychiatric nursing and additional appointments
 in child and adolescent psychiatry, psycho-geriatrics, co-morbidity, family
 intervention, and forensic psychiatry. 
• State education authorities need to provide appropriate undergraduate, 
graduate and continuing education programs. In particular, further 
programs are needed in community-based service delivery skills. 
• Governments and medical authorities should investigate the establishment 
of Institutes of Psychiatric Training in States where these do not exist. 
• Training courses should be as accessible as possible. Particular 
attention must be given to the needs of rural and isolated professionals. 
• Health employers should ensure that staff are able to attend continuing 
education and training programs. 
• Compulsory continuing education should be a requirement for reregistration, 
particularly registration of psychiatrists. 
• Trainee psychiatrists and psychiatric registrars must be provided with 
appropriate clinical supervision and support. 
• The training of general practitioners must place greater emphasis on the 
assessment and treatment of mental illnesses and mental health problems. 
• Tertiary-based nurse education programs must accord higher priority 
to mental health training. 

Page 912 Mental Illness Inquiry 

• Government Equal Employment Opportunity plans should provide specifically
 for the needs of people with mental illness and psychiatric disability. 
• Federal, State, Territory and local government employees delivering 
services to the public should receive appropriate training in the needs 
of people affected by mental illness. 

Inpatient Care and Treatment (Chapter 8) 

Findings: 

• The lack of crisis teams to assist with psychiatric emergencies sometimes 
places consumers and their families at serious risk. It also means that the
 police are often forced to intervene to take seriously ill people to hospital — 
'criminalising' the process and reinforcing stigma and fear in the community 
• The rights of people with mental illness to inpatient care in a safe, 
therapeutic environment are not being respected. Violations and abuse continue,
 and the universal right to treatment with humanity, respect and dignity is
 frequently disregarded. 
• Avenues to hear and investigate grievances by inpatients are inadequate. 
Where such avenues do exist, many people in psychiatric facilities are either 
unaware of or unable to access them. Patients are afraid of retribution by 
hospital staff if they make a complaint. 
• Some form of long-term institutional care must be retained for the small 
proportion of people whose psychiatric disability is so severe that they will
 not be able to live in the community. 

Recommendations: 

• Health departments should ensure an adequate number of trained psychiatric
 emergency or crisis teams — on call for 24-hours, seven days a week — in each
 health region in Australia. In areas where this is impracticable because of
 distance or small population, alternative mechanisms should be established,
 using, for example, local general hospital staff, a GP or a community nurse, 
with telephone access to a consultant psychiatrist. 

Human Rights and Equal Opportunity Commission Page 913 

• Independent hospital visitors (Official Visitors, Community Visitors, 
Boards of Visitors or their equivalents) should be appointed to oversee patient
 rights and welfare. They should be given appropriate formal powers of 
investigation regarding consumers' grievances and a clear line of responsibility
 to an executive officer with statutory powers, independent of the hospital 
administration. Jurisdictions without sufficient hospital visitors to undertake
 this role effectively should rectify this situation. Complaints should initially 
remain confidential and independent of clinical staff. 
• Independent, statutory complaints investigation bodies should be established in 
each State and Territory. 
• The ambulance service should be used wherever possible to transfer a person in 
an acute state of mental illness (who is unwilling to go by the usual means) to 
hospital. Police should be called upon as a last resort and, if genuinely required,
 unmarked police cars should be used, not divisional vans ('paddy wagons'). Police
 officers likely to be involved in these situations should receive appropriate 
training and should comply with a special code of practice. 
• Where a mentally disturbed or distressed person seeks admission to an inpatient
 psychiatric facility but does not appear to meet admission criteria, they should 
be afforded 'asylum' for one night or, at the very least, referred to mental health
 personnel or an appropriate agency which can provide immediate support. In no 
circumstances should individuals be turned away without any assistance. 
• General hospitals should develop and constantly review their psychiatric 
admission procedures to ensure the most appropriate assessment and treatment. 
• Hospital administrations must ensure that every person admitted to a 
psychiatric facility receives a full physical health check as soon as possible
 after admission. Physical health should be monitored for the duration of each
 person's stay and arrangements made for medical attention where required. 
• Staff should provide information to people on admission to hospital, or as 
soon as they are able to receive it, about their rights and responsibilities, 
complaint procedures, the names and roles of treating doctors and nurses, hospital
 rules and procedures, and daily activities. 

Page 914 Mental Illness Inquiry 

• Staff must inform patients about medication prescribed in hospital — including 
its effects, side-effects, duration of administration and frequency of review,
 anticipated outcome, associated risks, and possible alternatives. Patients
 should be given an opportunity to express views and ask questions of the
 prescribing doctor. 
• Prescribing doctors must review patient histories to ascertain suitability
 and effectiveness of specific medications. Medication should be carefully 
monitored and notations made inpatients' files for future reference. 
• Medication should only be administered for the welfare of inpatients and 
to alleviate the symptoms of their illness. Staff in hospitals should never
 use medication as a 'management tool'. 
• Alternatives to medication should be considered wherever appropriate. The 
views and preferences of the consumer should be considered at all stages of 
the treatment process. 
• Psychiatric facilities should provide a reasonable degree of privacy, 
room for and access to personal belongings, a comfortable environment, 
indoor and outdoor recreation space, and separate areas where patients can
 talk to visitors. 
• Hospital administrations should provide inpatients with opportunities for
 continuing and remedial education. 
• Protocols should be established for the use of seclusion. Seclusion should 
be employed only in the rarest of circumstances and only after all other nursing
 strategies have been attempted without success. Any seclusion room must 
have a toilet. 
• Attempts must be made to minimise the occurrence of assaults and abuse in 
hospitals by employing sufficient numbers of skilled psychiatric nurses and other
 mental health professionals committed to establishing therapeutic relationships 
with inpatients; by avoiding overcrowding or inappropriate patient mixes in wards;
 and by working to defuse tension and create a positive living environment. 
• All staff should be aware of the procedures for reporting assaults and other 
serious incidents. Allegations by inpatients should be followed-up immediately. 

Human Rights and Equal Opportunity Commission Page 915 

• A treatment plan should be drawn up for each inpatient as soon as 
practicable after admission. The plan should be regularly reviewed in consultation
 with the individual wherever this is possible. The preparation of plans for care
and treatment after discharge should commence early in the person's hospitalisation 
and should involve both the individual and appropriate family members, especially if
 they are to become carers. Community mental health workers and relevant community 
agency representatives should participate in the discharge planning process at least
 once before discharge takes place. 

• The discharge summary for each patient should include information about 
diagnosis, history (including previous medication), treatment provided, 
current status and current medication requirements. The discharge summary
 should be provided, with the individual's consent, to the person responsible
 for oversight of the individual's treatment after discharge. 

Inpatient facilities should collect data for service planning purposes
 regarding the anticipated accommodation arrangements for each person leaving hospital. 

Community Care and Treatment (Chapter 9) 

Findings: 

• The inadequacy of existing community mental health services to treat, care 
for, and support people with mental illness living in the community is disgraceful. 
Those services which do exist are grossly underfunded and 
underdeveloped. 
• Very few community mental health services have established systematic 
follow-up procedures. 
• There has been virtually no systematic retraining of psychiatric hospital 
staff to work with people in a non-institutional setting in the community. 
• There is little coordination between mental health services provided to people 
in inpatient psychiatric facilities and community mental health services. 

Page 916 Mental Illness Inquiry 

• Procedures for discharge planning and for co-ordination of services for 
community treatment and care of people with mental illness are generally 
inadequate and, in many instances, non-existent. 
• There are conflicting views regarding the compulsory administration of 
antipsychotic medication to people subject to Community Treatment Orders 
(CTOs). CTOs offer a form of involuntary treatment which is less restrictive 
than hospitalisation. If they become too intrusive, however, they are likely to 
be resisted and additional safeguards may be necessary. 

Recommendations: 

• Community mental health services should include an appropriate combination
 of inpatient facilities, crisis services, mobile teams, outpatient services,
 day programs, community outreach and follow-up, accommodation support, 
and rehabilitation programs (including social skills, living skills,
 recreation and health promotion, education, management and budgeting, 
self esteem building, medication management, where appropriate, and
 vocational rehabilitation). Non-
vocational rehabilitation programs must be provided for those whose disability 
makes employment unlikely. 
• Governments in all jurisdictions should institute procedures to ensure that
 community mental health services attain levels of mental health care and
 treatment such as those prescribed in the Area Integrated Mental Health Service 
Standards. 
Mental health services should not attempt to care for people with serious mental
 illnesses in the community until it can be demonstrated that appropriate 
accommodation and sufficient numbers of suitably trained community mental
 health staff are available to provide adequate care and support for them. 

• Governments in all jurisdictions should provide priority funding for 
psychiatric disability programs (including psychosocial rehabilitation), until
 funding for these services is at least equivalent to that provided for 
other categories of disability. 
• All departments and agencies involved in the community care of 
people with mental illness should develop and implement procedures 
to ensure effective inter-agency collaboration. 

Human Rights and Equal Opportunity Commission Page 917 

• Inter-agency training should be provided to familiarise staff with the needs 
of people with mental illness and appropriate responses to assist their integration 
into the general community. Other government and non-government workers who deal 
with the public should be given basic information about mental illness and the 
importance of treating consumers with respect. 
• Health administrations must allocate funding to retrain psychiatric hospital 
staff for community work. 
• The new Divisions of General Practice should encourage GPs to actively
 participate in community mental health services for people with mental illness
 living in the community. 
• Inpatient and community mental health service staff should work together to 
develop a practical management plan for every individual with a mental illness 
who comes into contact with either community or inpatient mental health services. 
The individual and appropriate family members should participate in the 
formulation of the management plan. 
• One person should be nominated to oversee the coordination of services for 
individuals who require access to a range of services. 
This person should establish and maintain a therapeutic relationship with the 
individual and ensure that, where appropriate, family members are included in decisions and management. 
• Legislation in all jurisdictions should make provision for compulsory treatment
 in the community. Mental health services should monitor compulsory Community 
Treatment Orders to evaluate their benefits, disadvantages and overall effectiveness. 
• The level of income support for people with chronic mental illness should be 
increased to provide an acceptable standard of living and to relieve some of the 
financial burden on carers. 
• The Federal Government should examine ways of increasing timely access to 
new drugs for the treatment of schizophrenia and other serious illnesses. 

Page 918 Mental Illness Inquiry 

Accommodation, Boarding Houses and Homelessness (Chapters 10, 11 and 18) 

Findings: 

• People affected by mental illness face a critical shortage of appropriate and 
affordable housing. The absence of suitable supported accommodation is the 
single biggest obstacle to recovery and effective rehabilitation. 
• Government housing programs for people with disabilities exclude many Australians
 with mental illness, due to inflexible criteria and poor coordination between 
departments and agencies. 
• A large proportion of people with mental illness live at home with their 
families, who urgently need more respite care. 
• Homeless shelters, refuges and boarding houses are now functioning, de 
facto, as a major component of the 'accommodation' provided by our society 
for thousands of Australians affected by mental illness. This is completely 
unacceptable. 
• Large numbers of Australians affected by mental illness live in boarding 
houses. Living conditions in many of these establishments are disgraceful — 
and completely unacceptable for people with disabilities. They rarely have 
trained mental health workers on staff and generally provide minimal 
opportunities for rehabilitation. 
• Boarding house staff are often involved in dispensing residents' medication, 
and usually have little or no training for this task. 
• The Supported Accommodation Assistance Program (SAAP), the main source 
of funding for crisis services for homeless people, excludes services specifically 
for people with mental illness. This is a major problem, given the very large
 number of homeless people affected by mental illness. 
• Some groups of people with mental illness are harder to place in accommodation,
 due to their age, special needs, personal circumstances, and/or discrimination.
 These include: Aboriginal people, ex-prisoners and those with a history of
 violence, young people, women with dependent children and individuals with
 dual or multiple disabilities. 

Human Rights and Equal Opportunity Commission Page 919 

Recommendations: 

• Supported accommodation for people with psychiatric disabilities must be established
 in all major metropolitan and regional centres. This should include crisis,
 medium-term and long-term accommodation. 
• In allocating places in supported accommodation, priority should be given to 
accommodating particularly disadvantaged groups (as identified in this report). 
• Support staff should be available to provide medical, counselling and life skills
 support. Their hours and availability should be appropriate to the needs of consumers. 
This support should be provided to consumers wherever they live, whether in 
designated special accommodation schemes or in public or private housing. 
• Hospital discharge plans should include appropriate accommodation placement.
 Local accommodation providers should be routinely consulted as part of discharge planning. 
• State and Territory housing departments should recognise the urgent needs of
 homeless people affected by mental illness and accord them priority. 
• Housing, health and community services departments should work together to 
provide supported accommodation which effectively meets the needs of people 
with disabilities. Each Government should nominate one department as the 
lead agency responsible for coordination of services. 
• People with a mental illness should be permitted to share their housing 
department accommodation with a carer (as are people with physical disabilities in some States). 
• Additional funding must be provided for respite accommodation for mentally
 ill people being cared for by their families. 
• Staff at shelters and refuges should be given appropriate training in 
dealing with people with mental illness. Some shelters may also wish 
to employ a mental health professional on staff. This must not be 
permitted to jeopardise their funding from the Supported Accommodation Assistance Program. 

Page 920 Mental Illness Inquiry 

• Hospital discharge summaries must be made available to any medical staff 
assisting shelters to which patients are referred, and discharge summaries
 should place greater emphasis on behavioural/ functional disabilities. 
• All boarding houses or similar facilities which have mentally ill people 
among their residents should be subject to stringent licensing and regulation by State governments. 
• Boarding house proprietors who fully comply with these regulations should
 be eligible for appropriate financial assistance. 
• One condition of licenses should be that boarding house proprietors must
 co-operate with community mental health support workers. 
• Funds for monitoring and enforcement personnel should be increased so that
 regulation will actually be effective. 
• Training programs should be required (and provided) for hostel and boarding
 house managers and staff, to improve their ability to care for people with
 mental illness appropriately. 
• As part of the National Evaluation of SAAP the current exclusion relating to 
people affected by mental illness should be eliminated. 
• Before someone affected by a mental illness is discharged from any medical 
facility, one department or agency should be allocated responsibility for 
arranging their accommodation. 

Employment (Chapter 12) 

Findings: 

• Vocational rehabilitation for people with a psychiatric disability has been 
neglected by governments. 
• A number of barriers combine to deny most people with a psychiatric 
disability the opportunity to obtain work commensurate with their abilities
 and interests. These include lack of access to vocational and educational
 training, the debilitating effects of psychiatric illness and treatments,
 job design and 
negative employer and community attitudes. 

Human Rights and Equal Opportunity Commission Page 921 

• The heterogeneous needs of people affected by mental illness mean that
 a range of graduated, transitional, vocational and rehabilitation services
 need to be developed to provide greater access to employment opportunities 
and more meaningful use of non-working time. 

Recommendations: 

• The Federal Government should undertake an examination of the vocational 
and rehabilitation support services it provides in order to: 
(1) better define the specific vocational needs of people with mental illness
 and (2) identify current deficiencies and gaps in service provision. 
• The Federal Government should develop and expand specific vocational services
 for people with mental illness. Generic vocational services should be made
 more accessible by ensuring that eligibility requirements and structures
 take account of the specific needs of people affected by mental illness. 
• The Federal Government should fund the development and publication of
 guidelines outlining the various forms of 'reasonable accommodation'
 employers could provide to people with mental illness. 
• The Federal Government should investigate the introduction of tax incentives
 or subsidies for employers who make special provision in the workplace for
 people affected by mental illness. 
The Federal Government should provide funding for the implementation of an
 education project aimed at employers and workers, and developed in conjunction
 with employer and union representatives, to combat negative attitudes and 
discrimination affecting the employment of people with mental illness. 

In the development and expansion of specific and generic vocational and 
rehabilitation programs for people affected by mental illness, the following 
issues should be addressed: 

a) The goals and preferences of individual participants need to be acknowledged 
and incorporated into program design. Programs should be flexibly structured to 
accommodate changes in an individual's illness and personal circumstances. 

Page 922 Mental Illness Inquiry 

b) Programs must be as accessible as possible. Issues such as geographic location,
 proximity to public transport, flexible operating hours, eligibility criteria 
and procedures should be taken into account. 

• The Federal Government should encourage the development of 'Clubhouse' or
 other effective programs based on transitional employment schemes. The
 Disability Services Act 1986 funding guidelines should be amended to ensure
 Clubhouse programs access to Commonwealth funds. 
• Services for people with mental illness must include a range of options that 
cater for both vocational and non-vocational needs. The Federal Government, in 
consultation with appropriate consumer organisations, should support a range of 
meaningful non-vocational programs to meet the needs of people with mental illness. 

Education and Training (Chapter 13) 

Findings: 

• Evidence to the Inquiry underlined the importance of education in any 
effective system of care. In many cases, however, special education programs 
and services are required to assist people with mental illness achieve their 
potential. The lack of these services means that those affected by mental 
illness are denied important opportunities associated with education and training. 
• There is a particular lack of educational programs for children and adolescents
 in hospital or participating in day programs. 

Recommendations: 

• A working party of Federal and State/Territory education representatives 
should be established, to clearly define, in consultation with people affected
 by mental illness, their educational and training needs over the full
 educational continuum (ranging from pre-school needs to tertiary and 
vocational studies) and to identify deficiencies in our educational and 
training system and problems with service delivery. 
• The Federal Government should fund an investigation of the practical 
application of the concept of 'reasonable accommodation' (prescribed in
 the Disability Discrimination Act 1992) as it applies to the 

Human Rights and Equal Opportunity Commission Page 923 

education of students with mental illness. Guidelines outlining the various
 forms of 'reasonable accommodation' in education services should be developed and publicised. 

• State education and hospital authorities should develop appropriate 
education and day programs for children and adolescents affected by mental illness. 
• Educational institutions and authorities should review their access and 
equity programs to ensure appropriate education, training and support 
services are made available to people affected by mental illness. 
• Education authorities should, in particular, develop and provide appropriate
 information, career guidance and counselling for students with mental illness. 
• Education authorities should also provide appropriate assistance with 
orientation and enrolments and special assessment and examination provisions for
 students affected by mental illness. 
• Education authorities should make special allowance for those individuals
 who, because of the onset of illness in early adolescence, lack the necessary 
'starter' or eligibility qualifications. 
• Educational authorities should offer staff awareness and professional 
development programs — with particular emphasis on skills development courses
 for teachers in primary, secondary and tertiary systems in the recognition
 of mental illness and liaison with appropriate community-based mental health professionals. 
• Education authorities should support the expansion of alternative education and 
training options in TAFE, and the expansion of training options provided 
by private and community agencies. 
• The Federal Government should ensure the provision of appropriate assistance
 and greater flexibility from DEET and CRS for students with mental 
illness undertaking tertiary study. 

Page 924 Mental Illness Inquiry 

Discrimination: The Personal Experience of Mental Illness (Chapter 14) 

Finding: 

People with mental illness experience stigma and discrimination in almost every 
aspect of their lives. 

Recommendations: 

• Insurance companies and superannuation schemes should ensure that eligibility 
criteria do not discriminate against people affected by mental illness. 
• Other providers of goods and services must be made aware of their legal
 obligations to people with psychiatric disabilities under Federal disability 
discrimination legislation. 
• Governments and non-government organisations should conduct public education 
programs to dispel the ignorance and misconceptions associated with mental illness. 
(See also findings and recommendations for Chapter 27 — Prevention and Early Intervention.) 

Carers (Chapter 15) 

Findings: 

• The serious lack of community mental health services means that carers carry 
an enormous and unreasonable burden of care for people with mental illness. 
• This burden has adverse effects on carers' physical, emotional and mental 
health and imposes heavy financial strains. 
• Carers are denied information and excluded from decisions concerning the 
care and treatment of people affected by mental illness. 

Human Rights and Equal Opportunity Commission Page 925 

Recommendations: 

• Governments must provide appropriate community mental health services 
(particularly crisis care) to alleviate the onerous burdens borne by carers. 
• A range of centre-based, home-based and holiday respite services should be
 made available for carers and consumers. 
• Eligibility criteria for HACC services and DNC benefits should be amended
 to accommodate the needs of carers. 
• Mental health professionals should involve carers in consultations about
 inpatient treatment and home care and treatment. 
• Mental health professionals should provide carers with written and oral 
information about diagnosis, medication (and its side effects), and proposed treatment. 
• Mental health professionals should provide consumers and carers with 
intensive home support in the first week after discharge from inpatient care. 
• Mental health professionals should ensure that carers' knowledge and 
understanding of the individual affected by mental illness are taken 
into account in decisions concerning treatment and follow-up. 
• Where there is an apparent conflict in the provision of information 
about an individual's progress and condition, mental health professionals
 must attempt to balance the rights of the consumer and the carer. 
• Governments should provide significant additional funding to carer support groups. 

Page 926 Mental Illness Inquiry 

Children of Parents with Mental Illness 
(Chapter 16) 

Findings: 

• Mental health professionals and service providers do not routinely inquire 
about the existence of any dependents when interviewing or admitting an adult 
with a mental illness. 
• As a result, very little is known about what happens to the children of 
mentally ill parents and their needs are largely ignored. Young people who do 
not receive appropriate support may be adversely affected for the rest of their 
lives. 
• Child and family support programs are needed urgently. 

Recommendations: 

• Mental health professionals should seek information about dependent children 
in cases where people present for treatment for a mental illness. Referrals 
must be made where necessary. 
Relevant government departments such as health, education, family services and 
community services should co-operatively plan, develop, fund and implement 
services which provide a range of family and child support services for 
parents affected by mental illness and their dependent children. 

Agencies must be resourced to develop programs to meet children's varying needs.
 These include support during a parent's hospital admission, ongoing support after 
their discharge, and a range of home-based, centre-based, school-based and 
community-based activities. 

Education authorities and child and adolescent mental health services should 
institute or modify school-based programs to provide support for school-age children
 with mentally ill parents. Authorities should support the programs being conducted 
on a limited basis by ARAFMI and encourage their expansion. 

Governments should allocate adequate resources to non-government agencies which
 provide programs for children and family members 

Human Rights and Equal Opportunity Commission Page 927 

where there is a mentally ill parent. Programs provided by both 
government and non-government agencies should collect usage data 
and comply with regular review and reporting requirements. 

Elderly People (Chapter 17) 

Findings: 

• General practitioners are the main contact point with the health system for 
elderly people, yet they often fail to recognise mental disorders in these 
patients. Depression, in particular, is undiagnosed and therefore untreated in 
a large number of cases. 
• General mental health services frequently fail to recognise and meet the needs 
of elderly people affected by mental illness. 
• Research and training on mental illness in the elderly are seriously deficient. 
• Many older people with dementia are being denied their right to treatment in 
the least restrictive environment: 
a) Approximately 3000 people with dementia are still confined to psychiatric wards. 

b) Inadequate support services in the community are forcing older people unnecessarily,
 or prematurely, into institutional care. 

c) Outdated, inappropriate design and funding arrangements for nursing homes result 
in some residents who have dementia being physically restrained or sedated as a method
 of control. 

• These practices frequently constitute serious human rights violations. 
• Carers of aged people with mental illness urgently need respite and other 
support services. 

Recommendations: 

• All medical students should receive some training specifically relating 
to psychiatric disorders in old age. 

Page 928 Mental Illness Inquiry 

• Increased education and information should be provided to GPs concerning diagnosis
 and treatment of mental illness in older people. 
• At the very least, each health area should have a psychiatrist 
specialising in mental disorders of the elderly, who is available to teach, assess
 patients and provide advice to GPs and other mental health professionals. 
• A specialist psychogeriatric service should be established in every health area 
(one team for every 25,000 local residents over 65). Such a specialist service 
should be multidisciplinary, mobile and community-based. It should coordinate 
all psychiatric facilities for elderly people in the area, including acute, 
rehabilitation, outpatient and inpatient care, as well as domiciliary services.
 The service should co-operate closely with the general geriatric health service,
 and maintain regular contact with all private psychiatrists, nursing homes,
hostels and GPs in the area. 
• Area guidelines should be drawn up to clarify the responsibilities of 
psychogeriatric and general geriatric medical services. 
• Nurse education should emphasise training in psychogeriatric skills. 
• Funding for research on mental illness in the elderly must be increased. 
• Patients with severe ambulant dementia should not be admitted to nursing homes 
or hostels where the layout cannot accommodate their need to move around. Such homes
 should modify their facilities or cease to admit these residents. 
• The revised formula for the Residential Classification Instrument 
should be assessed to determine its effect on the chronic problem of 
underfunding for dementia. If necessary the formula should be reviewed to increase 
the subsidy for residents with severe ambulant dementia. 
• The Charter of Rights for Commonwealth-funded nursing homes, and the associated
 monitoring scheme, should be extended to all State-funded homes. 
• Purpose-designed dementia facilities must be supported as a more humane and
 cost-effective form of accommodation than generic 

Human Rights and Equal Opportunity Commission Page 929 

facilities. Funds should be allocated immediately for the planning and 
construction of such facilities. 

• The support services for dementia sufferers and their carers in each 
health area should be coordinated through an office where carers can obtain all 
appropriate information and referrals. 
• Governments should provide additional respite care, home help, day centres and 
other support services for carers of elderly people with mental illness as a matter
 of urgency. 
• The Domiciliary Nursing Care Benefit should be increased and criteria which c
urrently operate to exclude many carers of dementia sufferers should be amended. 

Women (Chapter 19) 

Findings: 

• Some professionals place an over-reliance on symptomatology and purely medical
 models to the exclusion of psychosocial and environmental factors in diagnosing psychiatric disorders in women. 
• The significance of sex-role stereotypes in clinical judgements relating to 
mental health issues has not yet been sufficiently acknowledged. 
• Women are given insufficient information about their illness and proposed 
treatment. 
• The lack of specialised knowledge of Post Natal Depression (PND) and other 
women's disorders is a major impediment to improving diagnostic and treatment methods. 
• Women who have a history of childhood abuse, sexual assault or domestic 
violence are more likely to be affected by mental illness or mental health 
problems. 
• Allegations of assault and harassment of women inpatients by staff and other 
patients, or visitors, are common — and require effective complaints mechanisms. 

Page 930 Mental Illness Inquiry 

• There is a critical shortage of both emergency and long-term accommodation
 for women affected by mental illness and their children. 

Recommendations: 

• Pilot early intervention programs should be undertaken to examine: 
a) the links between violence and abuse and mental illness; 
b) the efficacy of non-medical treatments for mental illness and mental
 health problems; 
c) the aetiology of post natal depression and other psychiatric disorders 
that affect women; 
d) the prevalence of sex-role stereotyping and its effect on clinical 
judgements concerning women's mental health. 

• All medical students should receive training in psychiatric disorders 
and mental health problems in women. 
• Additional education and information should be provided to GPs and mental
 health professionals about the diagnosis and treatment of mental illness in women. 
• Greater emphasis should be placed on environmental and psychosocial factors
 in the diagnostic process. 
• GPs and mental health professionals should provide patients with clear and 
comprehensive information about: 
a) drugs which are being prescribed (including possible side effects and/or
 addictive potential); 
b) alternative non-pharmaceutical treatments. 

• Governments should establish specialist PND clinics so that women can remain
with their children, wherever possible, during treatment. 
• Treatment, counselling and rehabilitation of women who have suffered violence
 and abuse should address the situation directly and attempt to protect women
 from further harm. 

Human Rights and Equal Opportunity Commission Page 931 

• Hospital administrations should take appropriate measures to secure the safety
 of women who have been the victims of abuse during visits by partners.
 (Complaints procedures should be implemented and allegations of harassment
 or assault regarded as serious matters and investigated promptly.) 
• Governments must provide resources for supported emergency and long-term
 accommodation for women affected by mental illness who have children. 

Children and Adolescents (Chapter 20) 

Findings: 

• There is an extremely serious shortage of child and adolescent psychiatrists 
and other child and adolescent mental health professionals in most parts of 
Australia. 
• There are serious deficiencies in the provision of staff, services, facilities 
and programs for children and adolescents throughout Australia. 
• The whole field of child, family and adolescent mental health service 
provision is grossly underfunded, despite the fact that a third of our 
population consists of young people and that the average age of onset for
the most serious mental illnesses is 16 years. 
• There is an alarming lack of knowledge among many mental health, health, 
education, welfare and juvenile justice professionals about the various 
psychiatric, behavioural and emotional problems which can affect children and 
young people.
 
Recommendations: 

• Governments should allocate increased funding for child and adolescent mental
 health services as a matter of urgency. 
• Health departments should allocate significantly increased resources for the
 establishment or augmentation of adolescent community mental health clinics,
 drop-in centres for disturbed or mentally ill adolescents, and child and 
family outreach and home support services. 

Page 932 Mental Illness Inquiry 

• Health departments should allocate substantially increased resources to acute 
inpatient assessment and treatment facilities for children with mental illness
 or severe emotional or behavioural disturbance. Facilities should not be 
restricted to children with a diagnosable mental illness. 
• All medical students should receive training in child and adolescent mental health. 
• Education and information should be provided to GPs and mental health 
professionals about the diagnosis and treatment of mental illness and other 
serious disorders in children and adolescents. 
• Outpatient and day-patient mental health services for adolescents should be 
appropriate for the client group. 
• Government departments involved in the delivery of services for children, 
families and adolescents must ensure improved inter-agency coordination of 
services. Private and non-government service providers such as clinical 
psychologists, family therapists, GPs and relevant NGOs should be involved in 
establishing procedures for inter-agency coordination. 
• State and Territory mental health services, in collaboration with departments
 of family and community services, should provide more day programs for child,
 adolescent and family counselling and therapy and more in-home support. An 
appropriate campaign should be undertaken to increase awareness of and access
 to such services for families under stress. 
• Where mandatory reporting of suspected child abuse is introduced it must be 
accompanied by sufficient resources to enable reported cases to be properly
followed up. 
• Child and family services should develop protocols in consultation with GPs,
 health services, schools, social workers, police services, and any church
 or non-government organisations which may be relevant to follow-up action in
 cases where child abuse is established. 
• Teachers should receive special in-service training in identifying children 
who are at risk; referring children to relevant services; and, where appropriate,
 integrating children and adolescents with mental illness and emotional or
 behavioural disturbance into the classroom. 

Human Rights and Equal Opportunity Commission Page 933 

• Education authorities and tertiary institutions should seek to increase the
 number of school clinical psychologists in training and increase the numbers 
appointed to schools. 
• Education authorities should ensure that schools provide extra support 
or remedial education to children who have mental, emotional or behavioural 
problems themselves, or who are known to live in a dysfunctional or violent family. 
• Departments of family and community services should provide more appropriate 
accommodation for children and adolescents in crisis to avoid the placement of 
these young people in correctional or detention facilities. 
• Juvenile justice agencies should ensure that young people with mental illness or
 severe emotional or behavioural disturbance who are in detention receive specialist 
psychiatric assessment before being brought before the courts. The psychiatrist's
 assessment report must be provided to the magistrate or judge prior to 
determining placement of the young person. 
• Juvenile justice agencies should ensure that young people with a mental illness
 who are already under detention in either the juvenile justice system or the
 adult corrections system receive appropriate psychiatric assessment, ongoing
 treatment and regular psychiatric review. 
• Education authorities and mental health services should establish protocols 
for the provision of critical incident ('postvention') counselling programs 
in schools after a student has committed suicide. 
• Those governments which have not already done so should establish a 
multi-agency youth suicide prevention task force to devise a range of strategies 
to counter the rising incidence of youth suicide. 

Page 934 Mental Illness Inquiry 

People with Dual or Multiple Disabilities (Chapter 21) 

Findings: 

• Specialist services for the many thousands of Australians affected by mental 
illness and some other form of disability are almost non-existent. 
• People with dual or multiple disabilities are, consequently, shuffled from 
agency to agency — often without finding anyone who will assume responsibility 
for their care. 
• Service providers lack the specialist training and have insufficient resources 
to deal with dual or multiple disability. Misdiagnosis is common and treatment 
often inappropriate. This can have devastating consequences. 

Recommendations: 

• Disability, mental health and drug and alcohol services should assume 
joint or collective responsibility, as appropriate, for the assessment, 
treatment and rehabilitation of people with dual or multiple disabilities. 
• Agency workers should receive special training to deal with the particular
 problems confronting individuals with dual or multiple disabilities. 
• Priority should be given to addressing some of the most pernicious aspects 
of the existing 'system', including: 
a) The sexual abuse of female inpatients affected by mental illness and 
intellectual disability; 
b) The use of medication as a 'management tool', particularly in dealing 
with people with mental illness and intellectual disability; 
c) The lack of services to effectively address the prevalence of mental 
illness and substance abuse among young people and the homeless; 
d) Misdiagnosis of deaf people affected by mental illness; 

Human Rights and Equal Opportunity Commission Page 935 

• Governments should fund the establishment or expansion of facilities for 
individuals with dual or multiple disabilities who need intensive inpatient 
care and treatment. 
• Research into the aetiology, prevention, assessment and treatment of all
 areas of co-morbidity should be accorded a high priority. 

People in Rural and Isolated Areas (Chapter 22) 

Findings: 

• The provision of mental health services in rural and isolated areas is 
influenced more by economic factors than consideration for the basic rights of 
consumers. 
• The lack of facilities in rural and isolated areas means that people are often 
transferred to city hospitals or given inappropriate care in a local hospital. 
Community care is also frequently inadequate. 
• There are considerable strains on mental health professionals and GPs
 working in isolated areas. This makes it difficult to fill even the positions that exist. 
• People affected by mental illness (including carers and families) feel 
particularly isolated and excluded in small rural communities. 

Recommendations: 

• Health planners should ensure that the rights of people in rural and isolated 
areas to appropriate mental health services are respected. 
• Health departments should ensure that resources for dealing with acute mental
 illness are available in local hospitals and integrated with community services
 in rural and isolated areas. This process should include specialised training
 for nurses and GPs and, in appropriate circumstances, recognition of an 
expanded role for specially trained nurse practitioners. 
• Health departments should expand and upgrade community-based mental health
 services to provide follow-up care and support for those who do not require hospitalisation. 

Page 936 Mental Illness Inquiry 

• Professional networks should be strengthened to keep workers in isolated 
areas in touch with each other and in contact with city-based colleagues. 
• Governments should provide funding and support for self-help and support
 groups for consumers and carers in rural and isolated areas. 
• Greater recognition should be given to the benefits of using 'telemedicine' 
techniques to provide people in rural and remote areas with assessments and 
consultations involving input by city-based specialists. 
Governments should ensure that available technology can be more widely used. 

Aboriginal and Torres Strait Islander People (Chapter 23) 

Findings: 

• Not enough is known about the incidence or prevalence of mental illness 
among Aboriginal and Torres Strait Islander people. 
• The removal of children from their families, the dispossession of Aboriginal 
and Torres Strait Islander people and their continuing social and economic 
disadvantage have contributed to widespread mental health problems. However, 
mental health services rarely deal with the underlying grief and emotional 
distress experienced by Aboriginal people. 
• Mental health professionals have little understanding of Aboriginal culture 
and society. This frequently results in misdiagnosis and inappropriate treatment. 
• Existing mainstream mental health services are inadequate and culturally 
inappropriate for Aboriginal people. 
• Aboriginal communities do not have access to the knowledge or resources to 
care appropriately for many of their own people. 
• Many Aboriginal and Islander people are denied the right to adequate mental 
health services because they live in isolated areas. 

Human Rights and Equal Opportunity Commission Page 937 

• The removal of Aboriginal people from remote communities for treatment in 
town can be extremely destructive to their mental wellbeing. This is particularly
 so for elderly people. 

Recommendations: 

• Governments must provide funding and resources to enable Aboriginal 
community-controlled health services to develop and deliver appropriate 
mental health services to Aboriginal people. 
• Joint research projects should be undertaken by Aboriginal communities 
and mental health professionals to determine the nature and extent 
of mental illness among Aboriginal people. 
• Governments should ensure that mental health policy, planning and program 
delivery is developed in consultation with Aboriginal people. Tertiary courses
 for non-Aboriginal mental health professionals (particularly psychiatrists 
and nurses) should include material on Aboriginal history and contemporary Aboriginal society. 
• Mental health professionals should acknowledge the role and significance
 of traditional healers in certain communities. 
Priority must be given to training Aboriginal health workers and other 
Aboriginal community-based resource people as mental health workers. 
Health departments should identify positions for Aboriginal mental health
 workers in areas with significant Aboriginal populations. 
Aboriginal liaison officers should be employed by relevant mainstream 
service providers to improve communication and consultation at all levels
 of the mental health system. 
All government and non-government mental health services should provide 
cross-cultural training for staff. 
Mental health services for Aboriginal people should be expanded to include
 community development, mental health promotion and primary prevention, 
and crisis intervention services for individuals and families. 

Page 938 Mental Illness Inquiry 

• Mental health workers must consult with family and community members
 before deciding that any individual affected by mental illness requires
 care or treatment away from the community. 
Community members should be kept informed about the treatment, progress 
and likely return of anyone removed from their community. 
• Health and community services departments should, in consultation with 
Aboriginal representatives, develop guidelines for the care of elderly 
Aboriginal people in remote communities. 

People from Non-English Speaking Backgrounds (Chapter 24) 

Findings: 

• Mainstream services are not meeting the needs of large numbers of people 
from non-English speaking backgrounds — particularly women and the elderly. 
• People from non-English backgrounds often come into contact with the health 
system only when their illness has reached the acute stage. 
• There is a clear need for transcultural mental health services and specialist 
programs for individuals with particular needs, such as the survivors of torture 
and trauma. 
• Interpreters are both under-used and used inappropriately. 
• There is a dearth of information about the rates of mental illness among 
different ethnic communities. 

Recommendations: 

• State and Territory governments should establish transcultural mental health 
services and, as appropriate, specialist programs in each capital city. 
• States and Territories should take cultural issues into account in their 
mental health policies, program planning and service delivery. The employment
 of multilingual staff and staff with training in cross cultural issues should be encouraged. 

Human Rights and Equal Opportunity Commission Page 939 

• General practitioners, psychiatrists, nurses and mental health workers 
should receive appropriate training in cross cultural issues (especially 
in terms of symptomatology, diagnosis and assessment). The special problems
facing women and the elderly should be emphasised. 
• The composition of mental health review and guardianship bodies should 
reflect the multicultural nature of our society. 
• Appropriate use of interpreters should be standard procedure in hospitals
 and community mental health centres. 
• Interpreters working in the health system need to receive training in 
mental health issues and terminology. 
• Health departments should prepare information on mental illness and mental 
health services in consultation with ethnic communities and ensure that it 
is disseminated appropriately. 
• Non-government organisations supporting people from non-English speaking
 backgrounds who are affected by mental illness should receive adequate funding.
 Government and non-government services should collect usage data and observe 
regular review and reporting procedures. 

Forensic Patients and Prisoners (Chapter 25) 

Findings: 

• Mentally ill people detained by the criminal justice system are frequently 
denied the health care and human rights protections to which they are entitled. 
• The denial of treatment to mentally ill prisoners and ex-prisoners often leads 
to further criminal offending, longer incarceration and aggravation of their 
mental illness. 
• Mental illness does not equate with criminality, nor with a propensity for 
violence. Persistent criminal behaviour is not an indicator of mental illness. 
• Conditions in some Australian prisons and police cells clearly breach our 
international obligations under the ICCPR and the Standard Minimum Rules for 
the Treatment of Prisoners. Such conditions are particularly damaging to the 
health of detainees affected by mental illness or disorder. 

Page 940 Mental Illness Inquiry 

• The rate of mental illness or disorder is higher among women prisoners. 
However, mental health care for them is virtually non-existent. Thus women 
in prison are doubly disadvantaged. 
• Aboriginal and Torres Strait Islander people are massively over-represented 
in prison and police custody, and incarceration is particularly damaging to their
 mental health. Yet forensic mental health services are systematically failing to meet their needs. 
• Procedures for detecting and treating mental illness and disorder in the 
Australian criminal justice system are inadequate in all jurisdictions. 
• Serious injustice is being done to individuals who are found unfit to be tried 
or not guilty of an offence on the grounds of insanity. Indeterminate detention 
'at the Governor's Pleasure' is a clear breach of human rights. 

Recommendations : 

• Mentally ill people in the criminal justice system must be provided with appropriate treatment. 
• Seriously mentally ill prisoners should generally be treated in health 
care facilities, controlled and operated by public health authorities. 
• Police and Corrective Services departments should ensure that individuals detained 
in custody are appropriately assessed for mental illness or disorder. Whenever possible,
 the assessment should be performed by mental health professionals. People from
 high-risk groups (eg Aboriginal prisoners, first offenders and young people)
must always be assessed, even if they do not appear to be mentally disordered. 
• Police and Corrective Services officers should be given training to 
enable them to recognise the signs of mental illness. 
• The general practice of admitting prisoners to hospital only in designated 'forensic'
 beds should be discontinued. Seriously mentally ill prisoners should be admitted to 
psychiatric wards in general hospitals or acute care wards in psychiatric hospitals,
 unless they are medically assessed to be dangerous or pose a serious risk of absconding. 
Designated forensic beds in psychiatric hospitals should be retained only for those
 people who cannot be safely treated elsewhere. 

Human Rights and Equal Opportunity Commission Page 941 

• Penal systems which insist on keeping seriously mentally ill inmates in prison 
should provide separate — and appropriate — treatment facilities for women. 
• Mentally ill prisoners who remain in jail must have access to adequate treatment
 by mental health professionals. These professionals should be consulted before 
their patients are transferred between prisons, and also notified well in advance of release. 
• The health and corrective services sectors must co-operate to ensure that mentally
 ill offenders on probation or parole receive the treatment they need. 
• Mainstream mental health services must not discriminate against people with a
 forensic history. Selected community mental health centres should receive 
funding to develop specialist services for ex-prisoners and sentenced offenders 
living in the community. These centres should co-operate with prison medical 
services to ensure continuity of care for prisoners on release. 
• Periods spent in hospital for the treatment of a psychiatric illness or 
serious mental disorder during the course of a prison term should be regarded
 as time served for the purposes of calculating a prisoner's sentence. 
• A diagnosis of 'personality disorder' or 'behavioural disturbance' must not
 be used as an excuse for denying mental health care to individuals who need it. 
• Governments should recognise and support the work of community agencies which 
provide housing and other assistance to ex-prisoners. 
• Anyone ordered to be detained in custody after being found unfit to 
plead, or not guilty on the grounds of mental illness, should be detained in a
 health facility — not a prison. Administrative arrangements should be made 
between the courts, health and corrective services departments to ensure that 
these patients are not forced to wait in prison while a place is found in a health facility. 
• Decisions concerning the release of persons found unfit to be tried or not 
guilty on the grounds of insanity should be made by courts or independent
 specialist tribunals. These bodies should exercise 

Page 942 Mental Illness Inquiry 

determinative powers. The executive branch of government should not have 
the ultimate responsibility for release decisions. 

Mental Health Research (Chapter 26) 

Findings: 

• Despite the enormous costs of mental illness to our community, funding for 
mental health research in Australia is woefully inadequate. 
• There is an urgent need for research into all aspects of mental illness, and 
particularly into its impact on the most vulnerable members of our community 
— children and young people, the elderly, the homeless, women, Aboriginal 
and Torres Strait Islander people, those from non-English speaking backgrounds, 
rural Australians and prisoners. 
• Australia urgently needs a national database containing information on the 
prevalence of psychiatric disorders and the disposition and effectiveness of 
mental health services. 

Recommendations: 

• General funding for mental health research in Australia should be
 increased over the next three to five years to 2 percent of the direct
 costs of psychiatric care. This would necessitate an increase to at least
 $32 million per annum. (The increase should be staged and shared between
 the Commonwealth and the States and Territories.) 
• Priority should be given to attracting young graduates to psychiatric 
research as a career — and to retaining them in this career. 
• The augmentation of psychiatric research should occur within existing 
Australian medical research structures. 
• A high quality national data base, incorporating information on the 
prevalence of psychiatric disorders and the nature and effectiveness 
of mental health services, must be established. The data base should 
integrate, to the maximum extent possible, information from the 
Commonwealth, States and Territories, and from public and private 
psychiatric treatment facilities. 

Human Rights and Equal Opportunity Commission Page 943 

• Community support for mental health research should be encouraged by public 
education programs on mental illness and the rights of those affected by it. 
• Research into mental illness and psychiatric disability among the special needs
 groups identified by this Inquiry must be conducted as a matter of urgency. 
• Research into the effectiveness of community-based services should be supported. 

Prevention and Early Intervention (Chapter 27) 

Findings: 

• Prevention is possible and productive in many areas of mental health. Much 
of what we know about prevention, if systematically applied, could make a 
significant difference in the levels and severity of many mental health problems 
and the degree of disability associated with some mental illnesses. Unfortunately,
 this knowledge has not been systematically applied to prevention policies 
and programs for mental health. 
• Although the specific causes of serious mental illness have not yet been fully 
identified, many elements which increase risk are now understood. It may be 
possible in many instances to lessen risk by mitigating these factors. 
• The community has a poor understanding of mental health issues and generally
 lacks compassion for those affected by mental illness. The debilitating effects
 of stigma and discrimination further inhibit timely access to care, limit 
opportunities for treatment and recovery, and create difficulties in
rehabilitation and community living. 
• Social disadvantage often increases the difficulties faced by people with 
mental illness and those who are vulnerable and at risk of mental illness. 
Socioeconomic disadvantage may also lead to depression, anxiety and other 
mental disorders. 
• Cultural factors influence perceptions and understanding of unusual 
behaviour, and patterns of response and care. Not only is an understanding of 
relevant cultural issues essential for the provision of mental health care, but 

Page 944 Mental Illness Inquiry 

unless care is provided in culturally appropriate ways additional stresses occur,
 adding to the burden, illness and disability of those affected. 

• All groups with specific requirements — such as elderly Australians, 
homeless people, women, those with dual and multiple disabilities and forensic 
patients — face particular difficulties in terms of mental health problems. To 
be effective, prevention strategies must also address these associated factors. 
• There is now significant scientific evidence suggesting the effectiveness of 
early intervention programs in addressing serious mental illness (eg schizophrenia,
 bipolar disorder and depression). 
• In light of the growing evidence indicating a link between child abuse and the 
later onset of mental illness, effective child abuse prevention programs and 
family mediation programs are essential. 
• Timely access to care is unnecessarily complicated by a mental health system 
which continues to focus overwhelmingly on the treatment of illness, at the 
expense of 'pre-crisis' support and care for vulnerable individuals. The 
'compartmentalising' of services and the failure of departments to designate 
(and accept ultimate responsibility for providing), a coordinated response, 
contributes to the hardship suffered by many individuals. 

Recommendations: 

Note: A number of the findings and recommendations relevant to this chapter 
(for example, those relating to Aboriginal and Torres Strait Islander people,
 the elderly, women, children and adolescents, those in rural and isolated areas, 
people from non-English speaking backgrounds) have been incorporated earlier 
in the General Findings and Recommendations. 

• There should be a nationwide campaign to educate the general community — 
and specific groups such as young people at school — about mental illness. 
• Prevention programs for young people must address youth suicide, depression,
 conduct disorder and other disruptive behaviour, and take into account the
 needs of young homeless people, those involved with our 'juvenile justice 
system', and other groups with special needs. 
• Education, support, and respite must be provided for those who care 
for people with schizophrenia, dementia or other serious illness. 

Human Rights and Equal Opportunity Commission Page 945 

• Education of general practitioners, physicians and those who care for the elderly 
is a critical aspect of prevention. Much distress and suffering among elderly people
 can be ameliorated by better diagnostic skills and more appropriate care. 
• Programs for vulnerable women should include prevention counselling, stress
 management, development of support networks, self care, relaxation and assertiveness skills. 
• It is critical that women have access to preventive counselling programs after
 experiencing violence, such as rape, to prevent psychiatric disorder and long term morbidity. 

Accountability (Chapter 28) 

Findings: 

• Controls and safeguards to protect the rights of people with mental illness 
and ensure that they receive appropriate care vary considerably in different
 States and Territories. Procedures are inconsistent and mechanisms for monitoring 
compliance with standards are lacking. Many mental health facilities have not
 been accredited by independent accreditation bodies. 
• While some jurisdictions have statutory advocates to promote and protect the 
rights of people with disabilities, advocates do not always have adequate powers 
or resources to effectively protect people with psychiatric disabilities 
and do not exist at all in several jurisdictions. 

Recommendations: 

• The Federal Government must ensure there is a consistent set of basic 
controls and standards in every jurisdiction in Australia. 
• Health departments must apply minimum outcome standards, based on nationally 
consistent criteria, to all mental health services. 
• Health departments must develop optimal clinical standards and ensure they
are applied in all areas of mental health practice. 
• Procedures for quality assurance should be coordinated to ensure that 
universal coverage and a level of consistency are assured. 

Page 946 Mental Illness Inquiry 


• The RANZCP and other professional bodies responsible for mental health should 
develop substantive and procedural guidelines for peer review. 
• Monitoring mechanisms should be strengthened and incentives provided for compliance
 with national service standards. 
• Every State and Territory should have statutory advocates with powers extending to 
the protection of people affected by mental illness. 

Human Rights and Equal Opportunity Commission Page 947 

APPENDIX 1 

WITNESSES APPEARING BEFORE THE INQUIRY 

DATE HEARINGS1 
WITNESS 
8/4/91 Melbourne 
Mr N Rees President, Victorian Mental Health Board 
Ms J Luntz President, Coalition of Child and Adolescent Mental Health Professionals 
Ms E Anderson Secretary, Coalition of Child and Adolescent Mental Health Professionals 
Dr I Siggins Victorian Health Services Commissioner 
Dr D Copolov Director, Mental Health Research Institute of Victoria 
Dr M Leggatt Secretary, Schizophrenia Australia Foundation and Executive Director, 
Schizophrenia Fellowship of Victoria 
Mr D Eldridge Associate Director, Crossroads 
Mr P McDonald Program Director, Crossroads 
Ms J Plant Supported Accommodation Network, Crossroads 
Ms M Hamley Policy & Planning Director, Crossroads 
Ms B Horwood Representative, Melbourne District Health Council 
Ms T Bates Director, 
Victorian Community Managed Mental Health Services (VICSERV) 
Mr M El Hag Sector Development Project Worker, VICSERV 
Ms L Walsh Consumer 
Mr T Calabro Administrator, Epistle Post Release Centre 
Ms K Lancefield Welfare Worker, Epistle Post Release Centre 
9/4/91 Melbourne 
Mr D Sandor Youth Worker 
Snr Const H Adams Community Policing Squad, Victorian Police 
Mr T Lawson President, Guardianship Board 
Prof G Burrows Chairman, Mental Health Foundation of Australia, 
President, Mental Health Foundation of Victoria, 
Professor of Psychiatry, University of Melbourne 
Ms L Brophy President, Association of Mental Health Social Workers 
Prof B Tonge Head, Monash University Centre for Developmental Psychiatry and 
President, Australian Society of Adolescent Psychiatry 
Ms M Thorpe Coordinator, Victorian Aboriginal Mental Health Network 
Dr J McKendrick Melbourne University Dept of Psychiatry, St Vincent's Hospital 
Ms M Ray MP Chairperson, Social Development Committee, Parliament of Victoria 
Witnesses from other cities and towns also attended hearings in regional 
centres to present evidence. (For example, at the Ballarat hearings there 
were witnesses from Bendigo, Warrnambool and Hamilton — in addition 
to those from Ballarat itself.) 

Page 948 Mental Illness Inquiry 

Mr D Plant Research Officer, Social Development Committee, Parliament of Victoria 
Mr T Melbourne Coordinator, Victorian Mental Illness Awareness Council 
Ms J Robinson Hon Secretary, Victorian Mental Illness Awareness Council 


Mr R Salvage Advocacy Worker, Victorian Mental Illness Awareness Council 
Mr J Hughes Consumer
Fr P Nordan Brosnan Centre Youth Service, Catholic Prison Ministry 
Mr B Geary Director, Brosnan Centre Youth Service 
Prof B Singh Head, Dept of Psychiatry, University of Melbourne
Mr A Papakotsias Australian Greek Welfare Association 
Mr G Malageorgiou Action on Disabilities Within Ethnic Communities
Ms S Bailey Aboriginal Issues Unit of the Royal Commission into Aboriginal Deaths in Custody 

10/4/91 Melbourne 

Dr D Leonard Director, Clinical Services, Royal Park Psychiatric Hospital and 
Representative, Royal Australian and New Zealand College of Psychiatrists 
(RANZCP), Victorian Branch 
Dr M Duke Representative (RANZCP), Victorian Branch
Ms J Player Coordinator and two members, Association of Relatives and Friends of 
the Emotionally and Mentally 111 (ARAFEMI) 
Ms E Field Secretary, Victorian Branch, Australian Psychological Society
Ms M McMahon Member, Victorian Branch Executive, Australian Psychological Society 
Ms M Vidovich Assistant Federal Secretary, Australian Nurses' Federation 
Ms N Horton Coordinator, Council to Homeless Persons (CHP) 
Ms C Allison Coordinator, George Street Outreach, and member, CHP 
Ms M Campbell Health & Welfare Coordinator, Hanover Day Centre, and member, CHP 
Ms C Meese Assessment and Referral Team Ozanam House, and member, CHP 
Mr B Hagedorn Social Worker, Hanover Access Centre, and member, CHP
Mr F Hytten Chairperson, Mental Health Legal Service 
Mr P Johnson Solicitor, Mental Health Legal Service
Mr S Hird Solicitor, Mental Health Legal Service 
Ms T Smith President, Post and Ante-Natal Depression Association
Ms J Rogers Secretary, Post and Ante-Natal Depression Association
Ms J Ross Consumer
Mr R Johnson Researcher, TAFE
Mr R MacLellan MP Member, Social Development Committee, Parliament of Victoria 
Ms M Rowan Coordinator, Boomerang Club
Ms T Quinn Community Worker, Boomerang Club 
Ms J McNamara Social Worker, Boomerang Club 

11/4/91 Ballarat

Mr J O'Neill Administrator, Lakeside Hospital 
Mr P Faulkiner Project Officer assisting Mr O'Neill 
Mr P Humphreys Social Worker, Commonwealth Rehabilitation Service 
Mr K Burnett Senior Social Worker, Community Mental Health Service, Warrnambool 
Mr D Smith Regional Manager, Commonwealth Rehabilitation Service, Hamilton 
Mr D Pugh Coordinator, Bendigo Community Support Service 

Human Rights and Equal Opportunity Commission Page 949 

Dr D Wells Head, Forensic Medicine and Police Surgeon
Ms P McFadyen Aged & Disability Development Officer, Bendigo Councils
Ms W Leslie Carer
Mr G Hoogenboom Psychiatric Nurse, Bendigo Psychiatric Centre 
Ms J Atkinson Consumer 


17/6/91 Sydney 

Prof B Waters Professor of Child and Adolescent Psychiatry, University of NSW 
Ms J Said Executive Director, Aftercare Association 
Prof G Andrews Professor of Psychiatry, University of NSW and 
Director of Health Services Research Group, Clinical Research Unit for 
Anxiety Disorders, St Vincent's Hospital 
Dr J Ellard Director, Northside Clinic 
Ms R Gurr President, New South Wales Council of Social Services 
Ms M Smith Coordinator, Manic Depression and Depression Association 
Mr E Nimri Executive Officer, Mental Health Coordinating Council 
Dr E Bernardi Representative, RANZCP, NSW Branch 
Dr Campbell Representative, RANZCP, NSW Branch 
Dr S Einfeld Representative, RANZCP, NSW Branch
Ms J Meagher Consumer

18/6/91 Sydney 

Dr N Buhrich Acting Director, Dept of Psychiatry, St Vincent's Hospital
Ms P Lowrey Policy Officer, Consumers' Health Forum of Australia
Ms T Benson Chairperson, Mental Health Task Force
Ms A Davis Executive Officer, Association for the Relatives and Friends of the Mentally 111 (ARAFMI) 
Ms N James Consumer 
Mr J Lizzio National Administrator, GROW 
Mr W King National Program Coordinator, GROW 
Mr J Gillies Member, GROW 
Dr T Williams Director, Institute of Psychiatry, NSW
Dr M Dudley Psychiatrist, Avoca Clinic, Prince of Wales Hospital 
Mr D Gisz Consumer
Mr S Champ Consumer
Dr R Gurr Clinical Director of Psychiatry, Blacktown Community Health Centre 
Mr L Ridoutt Research Consultant 
Ms A Filis Research Consultant
Dr J Rey Director, Rivendell Child, Adolescent and Family Services, 
Royal Prince Alfred Hospital
Mr P Bioletti President, Mental Illness and Nervous Disorders Society (MINDS)
Mr A Nettleton Member, MINDS

Page 950 Mental Illness Inquiry 

19/6/91 Sydney 

Prof H Brodaty State & Federal President, Alzheimer's Association 
Ms P Jones Executive Director, Alzheimer's Association 
Ms T Waddell Carer 
Ms S Gentry Carer
Ms P Jones Chairperson, NSW Association for Mental Health 
Ms M Bull Vice-President, NSW Association for Mental Health 
Mr A Charles Wood Consumer
Ms A Newham Executive Director, Alliance for Mentally 111 Australia (AMI) 
Ms J Cant Member, AMI 
Mr R Ramjam Coordinator, Planning, Schizophrenia Fellowship of NSW
Ms M Walton Director, Complaints Unit, NSW Dept of Health
Mr B Hart Chelmsford Victims Action Group 
Ms M Como Chelmsford Victims Action Group
Dr A Rosen Director, Area Integrated Mental Health Services Project 
Ms W Weir Area Coordinator for Mental Health Services, Northern Sydney Area Health Service 
Private Hearing Carers 

20/6/91 Sydney
Dr J Hoult Director, Clinical Psychiatry, Glebe Community Care 
Dr R Barr Consultant Forensic Psychiatrist 
Ms M Lukes Founder of ARAFMI 
Ms M Cunningham Director of Service for the Treatment and Rehabilitation of Torture 
and Trauma Survivors (STARTTS) 
Ms R Becker Clinical Director of STARTTS 
Prof I Webster Professor of Community Medicine, University of NSW and 
President, NSW Association for Mental Health
Mr T Benjamin  Lecturer, School of Health Services Management, University of NSW 
Ms J Brown Carer 
Dr M Bashir Director, Dept of Community Health,Central Sydney Area Health Service
Prof J Snowdon School of Community Medicine, University of NSW 
Ms A Greener, Consumer

21/6/91 Sydney 

Sr P Swan Public Health Coordinator, Aboriginal Medical Service, Redfern
Dr E Hunter Psychiatrist, Aboriginal Medical Service, Redfern 
Ms M Smith Disability Council of NSW 
Ms M Sargent Disability Council of NSW 
Mr T Elligett Chief Executive, Psychiatric Rehabilitation Association 
Mr S Mailer Program Director, Psychiatric Rehabilitation Association 
Prof D Silove Professor of Psychiatry, University of NSW, Director of Mental
 Health Services, South Western Sydney Area Health Service and Macquarie Clinic,
 Liverpool Hospital 
Ms P Douglas Consumer 
Ms C Kendall Coordinator, LINK-UP (NSW) Aboriginal Corporation 

Human Rights and Equal Opportunity Commission Page 951 

Mr S Bowden Member, LINK-UP (NSW) Aboriginal Corporation 
Mr S Houston Chief Executive Officer of Tharawal Aboriginal Corporation 
Dr C McLeod PALA 

8/7/91 Sydney 
Ms J Eastgate National President, Citizens Commission on Human Rights 
Dr H Jolly Consultant Psychiatrist, NSW Department of Corrective Services 
Dr Y Skinner Consultant Psychiatrist, NSW Department of Corrective Services 
Ms L Cox Clinical Nurse Specialist in Mental Health 
Dr R Milton Forensic Psychiatrist 

9/7/91 Newcastle 
Prof R Morice Chief Executive Officer, Mental Health Services, 
Hunter Area Health Service 
Ms J Young Hamilton South Community Housing 
Ms F Rothero Hamilton South Community Housing 
Ms J Mulluley Hamilton South Community Housing 
Prof V Carr Head, Discipline of Psychiatry, Department of Medicine, Newcastle 
University, Newcastle Mater Hospital 
Ms M Sumner Member, ARAFMI 
Private Hearing Member, ARAFMI 
Private Hearing Consumer 
Mr B Herring Consumer 
Ms J Brown Secretary, Newcastle's Own Physically Handicapped 
Ms L Mason Manager, Newcastle's Own Physically Handicapped 
Ms L de Castro Lopo Acting Area Coordinator, Migrant Health Service, 
Hunter Area Health Service 
Mr R McDonald Ethnic Project Officer, Migrant Health Service, 
Hunter Area Health Service 
Dr S Tycehurst Psychogeriatrician, Morriset and James Fletcher Hospitals 
Ms N Hodgson Social Work Department, Hunter Area Mental Health Service 
Mr A Rose Social Work Department, Hunter Area Mental Health Service 
Private Hearing Carer 
Ms M Wilson Aboriginal Health Worker, Aboriginal Medical Service 
Mr S Griffin Researcher, Aboriginal Rehabilitation Survey, 
Newcastle Commonwealth Rehabilitation Service Office 
Private Hearing Consumer 

12/7/91 Orange 
Mr P Fanning Chief Executive Officer, Orange Health Service and 
Director of Psychiatric Services, Central Western Health Region 
Dr J Hoskin Medical Superintendent, Bloomfield Hospital 
Mr M Harris Team Leader, Mental Health Services, Dubbo 
Mr B Melvin Director, Mental Health Services, Orana and Far West Region 
Sr M Trainer Chaplain, Bloomfield Hospital 
Dr I Shochet Clinical Psychologist, Australian Psychological Society 

Page 952 Mental Illness Inquiry 
Mr N Rowlands Clinical Psychologist, Australian Psychological Society
Mr R Wortley Clinical Psychologist, Australian Psychological Society
Sr P Linnane Official Visitor, Bloomfield Hospital


9/8/91 Cairns 

Mr C O'Brien Consumer 
Mr R Stewart Outreach Worker, Youth Link 
Ms B Miller Coordinator, Aboriginal Coordinating Council 
Dr J Rigano Psychiatrist in private practice 
Mr G Holland Senior Community Psychiatric Nurse, Cairns Community Psychiatry Centre 
Dr J Wooldridge Psychiatrist, Cairns Community Psychiatry Centre 
Dr T Garrone Director of Psychiatry, Cairns Base Hospital 
Sr K O'Neill Housing Support Worker, St Vincent de Paul Society 
Ms M Knight Psychiatric Nurse and Crisis Counsellor, Ruth Women's Shelter 
Dr M West Psychiatrist, Flecker House, Cairns 
Ms M Kilpatrick President, ARAFMI, Atherton Tableland 
Ms J Lawrence Secretary, ARAFMI, Atherton Tableland
Ms E Colbert Carer and Member, ARAFMI, Atherton Tableland
Dr D Boyle Deputy Mayor and Chairperson of the Regional Health Authority 
Ms J Andrews Far North Queensland Families' and Prisoners' Support 
Ms G Ellis Social Worker, Community Advice & Information Centre, Innisfail 
Dr J Hiddlestone Representative, Allied Health Professionals for the Peninsula Region 

12/8/91 Townsville 

Ms M Gibson Coordinator, Migrant Resource Centre 
Ms S Bandaranaike Chairperson, Migrant Resource Centre 
Prof B James Chairman, Mental Health Association, Chairman, Queensland Country 
Psychiatrists' Association and Professor of Psychiatry, James Cook University 
Ms M Barra Carer 
Ms P Lang Friends for the Mentally 111 
Private Hearing Consumer 

Private Hearing Carer 
Private Hearing Coordinator, NGO 
Ms S Hale 'Concerned Citizens' Group 
Mr R Thompson 'Concerned Citizens' Group 
Senator M Reynolds Senator for Queensland 
Ms M Herring President, Schizophrenia Fellowship of North Queensland 
Mr M Drew Barrister 

13/8/91 Townsville 

Prof J Reser Department of Psychology, James Cook University 
Private Hearing Consumer 
Dr P Mildenhall Psychiatrist 

Human Rights and Equal Opportunity Commission Page 953 

14/8/91 Brisbane 

Ms M Broad Consumer 
Dr W Middleton Psychiatrist, RANZCP, Queensland Branch 
Carer Private Hearing 
Psychiatrist Private Hearing 
Ms S Tonkin Co-convenor, Mental Health Sub-committee, 
Queensland Council for Civil Liberties 
Mr J Thompson Chairperson, Mental Health Sub-Committee, 
Queensland Council for Civil Liberties
Ms C Davies Coordinator, Mental Health Action Group 
Ms J Graham Consumer
Ms C Kerr Occupational Therapist 
Ms D Pollard Occupational Therapist
Ms J Trevan-Hawke President, Queensland Assoc of Occupational Therapists 
Ms V Meyers Carer 
Ms J McLaughlin President, ARAFMI - Sunshine Coast
Private Hearing Carers
Private Hearing Carers
Private Hearing Carer
Private Hearing Consumer
Mr C Braddon Consumer
Mr P Swan Schizophrenia Fellowship Social Club 

15/8/91 Brisbane

Ms A Gulash Voluntary Worker, Aboriginal & Islander Community Welfare Service 
Mr T Watson President, Incarcerated Peoples Cultural and Heritage Aboriginal 
Corporation (IPCHAC)
Ms S Thorpe Community Welfare Worker, Aboriginal & Islander Community Health Service 
Mr Tony Marrows Social Worker, Aboriginal & Islander Community Health Service 
Mr B Lowah President, INNA, Torres Strait Islander Corporation 
Ms L Hallihan Community Worker, Queensland Advocacy Inc
Mr J Ward Lawyer, Queensland Advocacy Inc 
Mr T Wade Sub-committee Convenor, Queensland Association for Mental Health 
Ms B Johnson Coordinator, LINK-UP (Queensland) Aboriginal Corporation 
Dr W Bor Member, Faculty of Child Psychiatry, Queensland Branch, RANZCP 
Sr C Hefferan National Coordinator, Committee for People with Mental Illness, 
St Vincent de Paul Society 
Mr J O'Regan Consultant, St Vincent de Paul Society
Ms J Gray President, Schizophrenia Fellowship of South Queensland 
Mr O Hodgson Past President, Schizophrenia Fellowship of South Queensland 
Mr A Bowler Management Committee, Schizophrenia Fellowship of South Queensland 

Dr C Alroe Psychiatrist, Rockhampton 

Page 954 Mental Illness Inquiry 

16/8/91 Brisbane 
Mr S Hamlyn-Harris Barrister, Legal Aid Office, Queensland 
Ms E Bacon Member, ARAFMI 
Ms A Whitehead President, ARAFMI, Queensland 
Dr A Urquhart Director, Department of Psychiatry, Mater Children's Hospital 
Mr D Cheetham Consumer
Mr R Williams Queensland Wattle League for the Disabled
Private Hearing Consumer 
Private Hearing Carer
Private Hearing Carer
Dr J Lawrence Associate Professor, Department of Psychiatry, Royal Brisbane Hospital 
Ms M Lucas GROW 
Ms J Withel GROW
Ms M Graham Welfare worker, Inala Community House 
Private Hearing Consumer
Private Hearing Consumer
Private Hearing Nurse

18/10/91 Port Lincoln 

Ms V Gould Social Worker, Family and Community Services Department 
Ms M Shannon Administrator, Lower Eyre Peninsula Children's Emergency Hostel 
Ms M Brewster GROW 
Ms M Parsons Community Mental Health Nurse, Colbrook House 
Mr C Lowings Community Mental Health Nurse, Colbrook House 
Ms S Pearce Clinical Nurse Consultant, Whyalla Hospital 
Mr B Haynes Regional Training Officer, St John Ambulance Service 
Ms B Water Mental Health Projects Officer, 
Australian Nursing Federation, SA Branch 
Ms R Smith Social Worker, Geriatric Assessment Team, 
Department of Social Work, Port Lincoln Hospital 
Ms R Kinslow Social Worker, Central Clinic, Port Augusta Hospital 
Ms R Breen  Manager, Accommodation Services, Excell Enterprises 

21/10/91 Adelaide 

Ms C Caust Executive Administrator, Southern Child & Adolescent Mental Health Service (CAMHS) 
Dr S Allison Consultant Psychiatrist, Southern CAMHS and Flinders Medical Centre 
Ms P Mead Senior Community Mental Health Nurse, Southern CAMHS
Mr S Cornelissen Senior Community Mental Health Nurse, Southern CAMHS
Mr P Mulhearn Social Worker, Child Protection Service of South Australia 
Dr G Martin Psychiatrist, Southern CAMHS and Finders Medical Centre 
Dr J Clayer Director, Mental Health Research and Evaluation Unit, SA Health Commission 
Mr D Meldrum Director, Mental Health Unit, SA Health Commission 
Mr R Perkins Chairman, South Australian Mental Health Services Board, SA Health Commission 

Human Rights and Equal Opportunity Commission Page 955 

Prof S McFarlane Foundation Professor of Rehabilitation Psychiatry, University of Adelaide 
Mr L Mell Consumer
Ms D Gatoudis Consumer
Prof R Kosky Professor of Child Psychiatry, University of Adelaide, and Adelaide Children's Hospital 
Ms T Hatchett Consumer

22/10/91 Adelaide 

Ms L Dalston Director, Mental Health Association Resource Centre 
Ms M Heaton Manager, Disability Complaints Unit 
Ms L Wightman Consumer Advocacy Program
Dr D Ben-Tovin Associate Professor of Psychiatry, Director of Mental Health Services
Ms A Burgess Chief Project Officer, Mental Health Unit, 
South Australian Health Commission 
Mr R Barry Chief Executive Officer, Guardianship Board
Sr A Gregory Administrator, Catherine House Inc 
Sr M Tulley Deputy Administrator, Catherine House Inc
Mr R Chapman Social Worker, Southern Branch Community Accommodation Support Service (CASS) 
Ms B Fox Director, Panic Anxiety Disorder Association 
Dr M Battersby Psychiatrist, Flinders Medical Centre 
Mr R Woon Director and Chairman, Mental Health Action Group; 
Director, Self-Help MDP (Mood Disorders Prevention) 
Ms J Felus Administrator, Irene Women's Shelter 
Ms T Grime Coordinator, Domestic Violence Outreach Service  
Ms J Nelson Social Worker, Irene Women's Shelter 
Mr K Rainsford Program Coordinator, GROW
Mr B Mannock Consumer
Ms M Dobson Coordinator, Schizophrenia Fellowship 
Ms I Towler Executive Director, Schizophrenia Fellowship
Private Hearing NGO Representative 
Private Hearing NGO Representative 
Private Hearing NGO Representative 
Private Hearing NGO Representative 
Private Hearing NGO Representative

23/10/91 Adelaide 


Page 956 Mental Illness Inquiry 


Dr F Hawker Psychiatrist in private practice 
Mr L Cheers Director, Outback Health Service, Port Augusta Hospital 
Name withheld Carer 
Ms I Berzins Chairperson, Mental Health Review Tribunal 
Mr K Darwin Community Representative, Mental Health Review Tribunal 
Mr C Symes Solicitor 
Mr F Camatta Solicitor 
Ms U Dahl Human Services Consultant 
Ms D Price Chair, Management Assessment Panel for the Behaviourally Disordered 
Private Hearing Consumer 


11/11/91 Hobart 
Dr S Pridmore Director, Division of Psychiatric Services, 
Tasmanian Health Department 
Dr J Tooth President, Alzheimer's Association of Tasmania 
Mr J Leary Senior Policy Officer, Tasmanian Health Department 
Ms M Blackwood Regional Director, Southern Region Mental Health Services 
Dr S Morgan Consultant Psychiatrist, Clare House, Child and Adolescent Service 
Ms C Muskett Psychiatric Nurses' Committee, Australian Nurses' Federation (ANF) 
Mr J Pyrke Executive Director, Richmond Fellowship of Tasmania 
Mr C Pollard Director, Oasis Community Centre 
Ms M Nielsen Executive Officer, Langford House 

12/11/91 Hobart 
Dr R Pargiter Chairman, Ethics Committee, RANZCP 
Ms K Stanick Senior Social Worker, Gavitt House, 
Northern Suburbs Community Psychiatric Service 
Ms R Laver Clinical Psychologist, Australian Psychological Society, Tasmanian 
Branch 
Mr S Pinkus Clinical Psychologist, Clare House Child and Adolescent Service 
Mr P Donelly Chairman, Steering Committee, National Carers' Association 
Dr I Sale Chairman, Tasmanian Branch, RANZCP 
Mr R Redom President, Australian National Association for Mental Health (ANAMH) 
and Board Member, Royal Derwent Hospital, Tasmania 
Mr B Mansell Tasmanian Aboriginal Centre 
Ms A Kelly Researcher, Alzheimer's Disease and Related Disorders Society 
Ms J Allie Member, ROPES Self Help Group 
(Reaching Out to People with Emotional Stress) 
Ms P Elwell Member, ROPES 
Ms J Sherrington Consumer, and Founder Member, Breakthrough Manic Depression 
Support Group 
Ms P Ingram Member, ARAFMI, Hobart 
Ms B O'Halloran Member, ARAFMI, Hobart 
Ms G Stocks Member, ARAFMI, Hobart 

13/11/91 Hobart 

Dr J Matthews Senior Psychiatrist and Head of Service, 
Woodhouse Centre Psychogeriatric Service 
Ms E O'Brien Advocacy Worker, Home & Community Care Funded Program, 
Migrant Resource Centre 
Ms Z Pakulski Project Worker, Migrant Resource Centre 
Ms I Matthews Social Worker, Migrant Resource Centre 
Ms P Bourke GROW 
Ms F Gillespie Consumer 
Ms T Evans Chairperson, Domestic Violence Action Group 
Ms L Hodgson Member, Domestic Violence Action Group 
Ms B Mitchell Member, Domestic Violence Action Group 

Human Rights and Equal Opportunity Commission Page 957 


14/11/91 Devonport 
Dr M Roberts Psychiatrist in private practice 
Ms K Linahan Coordinator, Community Options Service, Launceston 
Ms E Holmes Chairperson, Migrant Resource Centre, Launceston 
Dr R Buttfield General Manager, NW Regional Health Board 
Dr R Schneider Director, Psychiatric Services, Northern Region 
Sr C Long Clinical Nurse Consultant, Acute Psychiatric Ward, Launceston General 
Hospital 
Private Hearing Carer 
Dr B Kerr Director, Psychiatric Services, North-West Region, 
Tasmanian Health Department 
Ms D Gora Member, ARAFMI, Devonport 
Ms A Bourchier Member, ARAFMI, Devonport 
Ms G Evans Member, ARAFMI, Devonport 
Dr T Avery Psychiatrist in private practice 
Prof I Jones Professor of Psychiatry, University of Tasmania 
Mr D Paine Save Our Hospital Organisation 
Mr P Johnson Member, ARAFMI 
Ms J West Outreach Worker, ARAFMI Home Care Service Pilot Project 
Ms C Phillips Field Worker, GROW 
Mr M Brakey Principal, Ulverstone High School 
Ms J McCulloch School Crisis Intervention Worker, Ulverstone High School 

10/2/92 Perth 
Dr J Dingle Assistant Director, Dept of Psychiatry, Princess Margaret Hospital
 for Children, and Secretary, Faculty of Child Psychiatry, RANZCP 
Dr J Leavelsey Chairman, Board of Visitors, Heathcote Hospital 
Ms M Leach Manager, Support Services, Outcare Civil Rehabilitation Council of WA 
Mr C Cooper Coordinator, Community Accommodation Support Program 
Ms L MacLeod State Secretary, Psychiatric Nurses' Association 
Mr P Marwick Senior Social Worker, Warwick Child and Adolescent Clinic 
Mr G Covich President, Schizophrenia Fellowship of Western Australia 

11/2/92 Perth 
Dr I Campbell Associate Professor, School of Law, University of Western Australia 
Dr D Lord Representative, RANZCP, WA Branch and 
Consultant Psychiatrist, Fremantle Hospital 
Ms A Weafne Researcher and Lecturer, School of Social Work, Curtin University 
Dr S Rostov Senior Consultant Psychiatrist, Multicultural Psychiatric Centre 
Dr D Jacobs Psychiatric Superintendent, Graylands Hospital 
Ms B Harris Coordinator, Emmanuel Centrecare 
Ms P Vanderwal Coordinator, Mentally 111 Need Defending (MIND) 
Mr T Fowke President, Mental Health Association of WA 
Private Hearing Psychiatric Nurse 
Ms E Hansen Chairman, Social Issues Team, Country Women's Association of WA 
Ms P Carberry Director, ARAFMI 
Ms A White ARAFMI 
Ms M Harries Vice President, Australian Association of Social Workers (WA Branch) 

Page 958 Mental Illness Inquiry 

12/2/92 Perth 
Mr K Wyatt Senior Policy Officer, Aboriginal Health Policy Unit, Health Dept
Ms P Dudgeon Head, Centre for Aboriginal Studies, Curtin University 
Dr H Pickett Psychologist, Centre for Aboriginal Studies, Curtin University 
Dr M Roberts Psychiatrist in private practice 
Ms L Chester President, Alzheimer's Association of WA 
Ms R Gripton Co-ordinator of Volunteers, Alzheimer's Association of WA 
Mr P McHale Administrator, Lefroy Hostel 
Dr N Hills Consultant Psychogeriatrician, Selby Lodge
The Hon K Wilson WA Minister for Health 
Dr G Smith Director of Policy & Planning, Mental Health Services, WA Health Dept 
Ms L Newby Director, Legislation Development Branch, WA Health Dept

14/2/92 Albany

Dr D Smith Regional Director, Great Southern Health Region, WA Health Dept 
Ms L Hayden Representative, Southern Aboriginal Corporation 
Ms J Hansen Chairperson, Albany Aboriginal Corporation
Mr D Coyne Aboriginal Field Officer, Narrogin
Ms T O'Neill Co-ordinator, Albany Community Mental Health Team
Mr P Goode Manager, Milgrey House 

Mr C Ging Community Mental Health Nurse, South West Region (Bunbury) WA Health Department 
Private Hearing Carer 
Private Hearing Carer 
18/3/92 Canberra 
Dr A Jorm Social Psychiatry Research Unit, Australian National University 
Ms L Steeper Convenor, Mental Health Task Force, ACT Council of Social Services (ACTCOSS) 
Dr T Heins Psychiatrist, Phillip Child and Adolescent Service 
Dr J Cubis Liaison Psychiatrist, Woden Valley Hospital 
Mr R Gale Co-ordinator, Mental Health Resource 
Ms M Cooper Representative, Schizophrenia Fellowship, Canberra 
Ms P Daniel Secretary, Mental Health Foundation and 
Secretary, Manic Depressive Support Group 
Mr C Staniforth Chief Executive Officer, Legal Aid Commission of the ACT 
Ms K Fryar Assistant Executive Officer, Legal Aid Commission of the ACT 
Dr S Rosenman Director, Psychiatric Ward, Woden Valley Hospital 
Mr B I'Anson President, Mental Health Foundation 
Mr B Aldcroft Ainslie Village Limited 
Ms R Croton Ainslie Village Limited 
Ms C Stuart Legal Researcher 

Human Rights and Equal Opportunity Commission Page 959 

19/3/92 Canberra 

Mr B Bailey Acting Community Advocate 
Mr K Horsham General Manager, Housing & Community Services Bureau, 
ACT Corrective Services Department 
Ms R Nairn Social Worker, Phillip Child and Adolescent Service 
Dr B Hughson Executive Director, Mental Health Services, ACT Board of Health 
Dr Andy Butlin Director, Alcohol & Drug Service, ACT Board of Health 


21/7/92 Darwin 

Dr B Tyler President, NT Association for Mental Health 
Ms J Huck Senior Vice-President, NT Association for Mental Health 
Ms L Palfy President, NT Alzheimer's Association 
Ms D Hall Community Dementia Worker, NT Department of Health and Community Services 
Ms D Marshell Assistant Manager, Keefe Centre for Homeless Men 
Mr B McMahon St Vincent de Paul Society and NT Association for Mental Health 
Ms G Payne Co-ordinator, GROW 
Kirsty GROW member 
Ms C Scally Management Committee, DAWN House 
Ms S Fogarty Director, DAWN House 
Ms S Ross Director, Danila Dilba Aboriginal Medical Service 
Ms G Lawton Aboriginal Health Worker, Danila Dilba Aboriginal Medical Service 
Mr G Norris Psychiatric Nurse, NT Department of Health and Community Services 
Ms C Darling Aboriginal Mental Health Worker, NT Department of Health and Community Services 
Mr J Lawrence Solicitor, North Australian Aboriginal Legal Aid Service 
Dr M San Pedro Medical Officer in Charge, Migrant Mental Health, NT Department of Health and
 Community Services 
Ms W Carrington Social Worker, Migrant Mental Health, NT Department of Health and Community Services 
Ms C Beaver Manager, Darwin Urban Mental Health Service 
Mr P Mels Manager, Forensic Team, NT Mental Health Services 
Dr J Ridley Director, NT Mental Health Services 

23/7/92 Alice Springs 

Dr Ohn Kyaw Director of Psychiatry, Alice Springs Hospital and Alice Springs and Barkly Districts 

Mr J Hopkins Co-ordinator, Disability Services of Central Australia (DISCA) 
Ms Jo Harrison Project Officer, Central Australian Advocacy Service 
Ms M Collins Administrator, Central Australian Advocacy Service 
Dr L Barnes General Practitioner, Alice Springs 
Mr T Cox Senior Psychologist, NT Department of Health and Community Services, 
Alice Springs and Barkly Districts 
Ms S de la Hunt Regional Manager, Southern Region, Commonwealth Rehabilitation Service 
Mr D Stradling Social Worker, Vocational Unit for Psychiatric Rehabilitation, 
Commonwealth Rehabilitation Service 

Page 960 Mental Illness Inquiry 


Mr P Warren Occupational Therapist, Mental Health Services, 
Alice Springs Hospital and Community House 
Ms S Jefford Director of Psychiatric Nursing, Mental Health Services, 
Alice Springs Hospital and Community House 

Human Rights and Equal Opportunity Commission Page 961 


APPENDIX 2 WRITTEN SUBMISSIONS 

GLOSSARY: 

NGO Non Government Organisation (including support organisations of consumers, 
relatives and friends) 

CRO Church Related Organisation 

Govt Government 

Prof Assoc Professional Association 

ISOH Independent Statutory Office Holder 


The classification system used in this appendix is, of necessity, arbitrary. It is included to
 give an indication of the range of individuals and organisations that took the trouble to 
prepare written submissions to the Inquiry and to acknowledge their extremely important contribution. 

VICTORIA 
NO NAME 
1. Ms H Adams Police officer
2. Action on Disabilities within Ethnic Communities NGO
3. Prof R Adler Psychiatrist
4. Name withheld Consumer
5. Mr D Anderson Consumer
6. Ms L Anthony Consumer
7. Association of Relatives and Friends of the Emotionally and Mentally 111 (ARAFEMI) NGO
Australian Nursing Federation Prof Assoc 
9. Mr H Baginski Consumer
10. Ms T Bates, Victorian Community Managed 
Health Services (VICSERV) NGO
11. Ms G Bell Consumer
12. Mr R Bell Concerned Citizen
13. Mr S Biondo, Fitzroy Legal Service NGO
14. Mr M Blandin de Chalain, Sunshine/Keilor Mental Health Forum NGO
15. Name withheld Consumer
16. Ms M Blythman Carer
17. Ms V Boston, St Kilda City Council Local Govt 
18. Mrs M Bramall Carer
19. Mr R Bridges Consumer
20. Mr J Briggs Carer
21. Name withheld Consumer
22. Ms E Burnell Concerned Citizen
23. Ms L Brophy, Association of Mental Health Social Workers Prof Assoc 
24. Ms A Brown, Melbourne District Health Council NGO
25. Mr J Caldwell Consumer 
26. Ms J Cameron, Port Melbourne Baptist Church CRO 

Page 962 Mental Illness Inquiry 

27. Mr C Campbell, Citizens' Commission on Human Rights NGO
28. Ms M Carmody Consumer
29. Mr F Carnegie Consumer
30. Mr P Chambers Consumer
31. Name withheld Consumer
32. Dr J Clarke, Prahran City Parish Mission CRO
33. Mr H Clausen (on behalf of a number of psychologists) Psychologist
34. Ms J Clements Carer
35. Dr P Cook, Kororoit Community Mental Health Service Psychologist
36. Dr D Copolov, Mental Health Research Institute of Vic Research Psychiatrist
37. Ms H Cousland Psychiatric Nurse
38. Name withheld Consumer
39. Ms P Crosthwaite Carer
40. Ms P Dasic Carer
41. Ms R Dawson, Port Melbourne Baptist Church CRO
42. Ms A Deveson, Schizophrenia Australia Foundation NGO
43. Mr D Dixon Consumer
44. Ms D Dowell Consumer 
45. Name withheld Carer
46. Doyle, Considine Solicitors
47. Mr I Eames, Wodonga Moodswing Self Help Group NGO
48. Dr P Eisen, Office of Psychiatric Services, Victorian Health Dept Govt
49. Ms E Field, Australian Psychological Society Prof Assoc
50. Fintry Bank Supported Accommodation Project NGO
51. Mr J Flynn, Victorian Deaf Society NGO
52. Name withheld Consumer
53. Name withheld Carer
54. Ms J Gee, Mental Health Legal Centre NGO 
55. Name withheld Consumer
56. Dr F W Grahame Psychiatrist 
57. Ms M Guthrie, People Against Power Abuse NGO 
58. Dr S Hacker Psychiatrist
59. Ms M Hage, Alcohol Related Brain Injury Assessment, Accommodation Support Inc NGO 
60. Mrs E Halley Carer
61. Ms B Harrison, Association for the Support of Psychiatric Services NGO 
62. Health Department of Victoria Govt
63. Mr B Healy, Dept of Social Work La Trobe University Academic 
64. Ms L Hepburn, Inner City School Support Centre NGO 
65. Dr H Herrman, Senior Lecturer, Monash University Psychiatrist, Academic
66. Mr G Hoogenboom Psychiatric Nurse 
67. Mr P Horan Carer
68. Ms P Horner, Ballarat Psychiatric Fellowship NGO
69. Ms N Horton, Council to Homeless Persons NGO
70. Ms N Hotchin Carer
71. Mr P Humphries, Commonwealth Rehabilitation Service Govt
72. Mr W Issell, Out Doors Inc NGO
73. Dr H Jackson Psychologist
74. Ms R James, Western Region Women's Response Group NGO
75. Dr R Jamieson, Bendigo CAE Academic
76. Mr G R Johnston, Northern Metropolitan College of TAFE Academic

Human Rights and Equal Opportunity Commission Page 963 

77. Mr P Kaye Consumer 
78. Dr B Kenny, RANZCP Prof Assoc
79. Mr J Klement Consumer
80. Ms K Lancefield, Epistle Post Release Service CRO
81. Ms J Lane Consumer
82. Mrs J Lawrence & Mrs M Robinson Carers
83. Dr M Leggatt, Schizophrenia Fellowship NGO
84. Mrs W Leslie Carer 
85. Mrs L Light, Uniting Church Ballarat, Central Parish Mission 
Outreach Centre CRO
86. Mrs J Lococo, Support Group for Relatives of People with a 
Psychiatric Disability NGO
87. Ms J Luntz, Coalition of Child & Adolescent Mental Health 
Professionals Prof Assoc
88. Name withheld Consumer
89. Mr R McCaig Consumer
90. Mr S McGrath Consumer
91. Mrs M McCutcheon Consumer
92. Ms P McFadyen, Bendigo Sub-Region Aged & Disability Services Development Committee NGO
93. Dr P McGorry, Early Psychosis Research Centre Research Psychiatrist 
94. Mr A Mackenzie Carer 
95. The Hon R Maclellan, MLA Member of Parliament 
96. Ms M McQueenie, Australian National Association for Mental Health NGO
97. Mrs R Mahar Consumer
98. Ms V Mancini, Ethnic Communities & Mental Health Issues Sub-Committee of VICSERV  NGO 
98. Mr D Mandic Consumer
99. Mr B Martyn Concerned Citizen 
100. Mrs V Mason Consumer 
101. Mr M Mead, Outer East Council for Developing Services in Mental Illness NGO
102. Mr T Melbourne, Victorian Mental Illness Awareness Council NGO
103. Mr G Merry Consumer
104. Dr H Minas, Victorian Transcultural Psychiatry Unit Psychiatrist
105. Ms S Mortimer Consumer
106. Mr V Mouradian Consumer
107. Name withheld Carer 
108. Mr T Nicholson, Hanover Welfare Services NGO
109. Ms M O'Donoghue, Changing Attitudes Towards Schizophrenia NGO
110. Ms L Oke, Australian Association of Occupational Therapists Prof Assoc
111. Mr O O'Flynn Community Visitor
112. Mr P O'Leary Carer
113. Mr G Ooi Consumer
114. Dr J Opie, Australian Catholic Health Care Assoc CRO
115. Outdoors Inc NGO
116. Dr W Orchard, Prince Henry's Hospital Psychiatrist 
117. Mr G Overton, The Melbourne Clinic Manager, Private Clinic
118. Mr A Papakotsias, North Eastern Alliance for the Mentally Ill NGO
119. Dr C Paul, Royal Children's Hospital Psychiatrist

Page 964 Mental Illness Inquiry 

120. Mr M Pavone, Australian Catholic Health Care Assoc CRO 
121. Ms V Peacock Speech Pathologist 
122. Mr E Place Consumer 
123. Mrs J Player, ARAFMI NGO 
124. Mr D Pugh, Community Support Program NGO 
125. Mrs J Rainbow Consumer 
126. Name withheld Consumer 
127. Mr R Reynolds Consumer 
128. Name withheld Consumer 
129. Richmond Fellowship of Victoria NGO 
130. Mrs M Roberts Consumer 
131. Name withheld Consumer 
132. Ms P Ronnau, Victorian Advisory Council on Recreation 
for People with Disabilities NGO 
133. Ms J Ross Consumer 
134. Mr D Sandor Youth Worker 
135. Mr S Sarma Consumer 
136. Mr B Scates Concerned Citizen 
137. Dr I Siggins, Health Services Commissioner, Victoria ISOH 
138. Ms T Smith, Post and Ante-Natal Depression Association NGO 
139. Mrs V Smith Carer 
140. Ms G Snaauw Consumer 
141. Mrs J Stjepovic Carer 
142. Mr H Strnad, Humanist Society of Victoria NGO 
143. Ms T Swanborough, Royal District Nursing Service Psychiatric Nurse 
144. Ms C Taylor, Health Services Commissioner's Office ISOH 
145. Ms C Taylor Consumer 
146. Mr I Taylor, Marjorie Oke Rooming House NGO 
147. Ms M Thorpe, Koori Mental Health Network/Victorian Aboriginal Health Service Co-operative NGO 
148. Mr R Trowbridge, Dept of Leisure Studies, Phillip Institute of Technology Academic 
149. Ms S Turale, Ballarat University College Nurse, Academic 
150. Ms S Vernon, North West Community Resource Exchange NGO 
151. Mr G Walker, Australian Guidance & Counselling Association Prof Assoc 
152. Ms L Walsh Consumer, Student 
153. Mr M Warnock Consumer 
154. Dr D Wells, Director of Forensic Medicine and Police Surgeon Govt 
155. Mr R Wiggins, Daily Activity for Self Help NGO 
156. Mrs J Willman Carer 
157. Ms C Wilson, St Kilda Community Health Centre Govt 
158. Name withheld NGO 
159. Ms M Wynne, Macaulay Community Support Program NGO 
160. Mr F Wright, Executive Director, Outer East Council for Developing Services in Mental Health NGO 
161. Mr G Yates Concerned Citizen 
162. Victorian Government Govt 

Human Rights and Equal Opportunity Commission Page 965 

NEW SOUTH WALES 
NAME CLASSIFICATION 

163. Prof G Andrews, Director, Clinical Research Unit for Anxiety Disorders Psychiatrist
164. Name withheld Social worker
165. Mr R Bailey Concerned Citizen
166. Mr K Baker Carer
167. Dr R Barr Psychiatrist
168. Name withheld Consumer
169. Mr C Beaumont Concerned Citizen 

170. Ms M Bell, Volunteer Centre of NSW NGO
171. Mr T Benjamin 
172. Dr R Beran Academic Neurologist
173. Mr P Bioletti, Mental Illness and Nervous Disorders Society (MINDS) NGO
174. Mrs D Blenman Carer 
175. Ms A Blitz Psychotherapist
176. Name withheld Consumer
177. Dr B Boettcher Psychiatrist 
178. Ms M Bowles Consumer
179. Name withheld Carer
180. Name withheld Carer
181. Name withheld Carer
182. Mr P Bright Consumer
183. Dr H Brodaty, President, Alzheimers Disease and Related Disorders Assoc (ADARDS) NGO
184. Mr G Brown Consumer
185. Name withheld Consumer 
186. Mrs J Brown Carer
187. Mr D Bryson-Taylor, Alliance for the Mentally Ill, Australia NGO
188. Dr N Buhrich, Psychiatric Department, St Vincents Hospital and 
Inner City Mental Health Service Psychiatrist
189. Name withheld Consumer
190. Mrs J Cant Carer
191. Prof V Carr, Dept of Psychiatry, Newcastle University and Mater Hospital, Newcastle Psychiatrist
192. Ms F Carr-Boyd Carer 
193. Sir John Carrick Concerned Citizen
194. Mr S Champ Consumer
195. Name withheld Consumer
196. Name withheld Consumer
197. Ms J Clements Consumer
198. Ms E Clough Consumer
199. Ms C Coad Carer
200. Mr R Coady, Unemployed People's Embassy NGO
201. Ms L Cole, Mental Health Co-ordinating Council NGO
202. Mr A Collins Concerned Citizen
203. Rev P Collins Concerned Citizen
204. Ms M Como, Chelmsford Victims Action Group NGO
205. Ms L Cox Psychiatric Nurse

Page 966 Mental Illness Inquiry 

206.Name withheld Consumer 
207.Ms M Cunningham, Service for the Treatment and Rehabilitation of Torture and 208.Trauma Survivors NGO
209.Mr G Curry, Faculty of Nursing, Kuring-Gai CAE Academic
210.Ms H Cusack Consumer 
211.Ms J Dilli, Ballina District Community Services Association NGO 
212.Name withheld Consumer 
213.Ms P Douglas Consumer Name withheld Consumer
214.Dr M Dudley, Avoca Clinic, Prince of Wales Hospital Psychiatrist
215.Mr J Du Ross Carer
216.Ms J Eastgate, Citizen's Commission on Human Rights NGO
217.Name withheld Consumer
218.Dr J Ellard, Director, Northside Clinic Psychiatrist
219. Mr T Elligett, Psychiatric Rehabilitation Association NGO
220.Ms V Eyles Concerned Citizen
221.Mr M Fabre Concerned Citizen
222. Name withheld Carer 
223. Ms M Fernandes Consumer
224.Ms C Flynn, Mental Health Co-ordinating Council NGO 
225.Ms J Fraser, Disability Council of NSW NGO 
226.Mrs A Gabeler Carer
227.Name withheld Carer
228.Mr D Gisz Consumer
229.Name withheld Consumer
230.Name withheld Consumer
231.Ms M Graden Consumer
232.Mr I Graham Consumer
233.Ms M Graham Social Work Student
234. Mrs E Gray Concerned Citizen
235.Ms R Greene, Association of Relatives and Friends of the Mentally 111 (ARAFMI) NGO
236.Ms A Greener Social Worker
237.GROW NGO
238.Ms R Gurr, NCOSS NGO
239.Name withheld Consumer
240.Mr N Hampton Concerned Citizen
241.Mr C Harbaum, Federation of Ethnic Communities Councils of Australia NGO
242.Mr M Harris, Mental Health Services, Dubbo Govt
243.Name withheld Consumer
244.Mr B Hart Consumer
245. Sr P Hartley, Bloomfield Hospital Psychiatric Nurse
246.Ms J Hawley, Psychiatric Rehabilitation Association NGO
247.Ms P Haylen Concerned Citizen
248.Mr A Helman Nurse
249.Rev H Herbert, Uniting Church in Australia CRO
250. Mr B Herring Consumer
251.Mr B Hill, Schizophrenia Fellowship NGO

Human Rights and Equal Opportunity Commission Page 967 

252. Mrs J Hodgess, Association of Relatives and Friends of the 
Mentally 111 (ARAFMI) NGO 
253. Name withheld Consumer
254. Ms N Hodgson Social Worker
255. Mr A Hogan Concerned Citizen
256. Mrs L Holland Carer
257. Name withheld Carer
258. Name withheld Carer
259. Dr J Hoult, Clinical Director of Psychiatry, Glebe Community Care Psychiatrist
260. Dr C Howe, Hunter Medical Association Prof Assoc
261. Mr D Hunt Consumer 
262. Dr E Hunter, Psychiatrist, Redfern Aboriginal Medical Service NGO 
263. Mr G Hutchison Carer
264. Mr C Jacob Consumer
265. Name withheld Consumer
266. Ms P Jockel Consumer
267. Names withheld Carers
268. Ms P Jones, Alzheimer's Association NGO
269. Mr P Joyce Consumer
270. Name withheld Carer
271. Mr D Kashyap Carer
272. Mr D Kavanagh Clinical Psychologist
273. Mr P Kelly Consumer
274. Ms C Kendall, LINK-UP NGO
275. Mr V Kenny Consumer
276. Mr A Keogh Concerned Citizen
277. Mr S Kinkead, New Horizons Disability Services NGO
278. Mr B Lane Concerned Citizen
279. Dr J Lennane Psychiatrist
280. Mr A Lewis Concerned Citizen
281. Mr A Lisle Concerned Citizen
282. Ms M Long Consumer
283. Mr M Longhurst, Ryde-Hunters Hill Mobile Treatment Team Govt
284. Name withheld Carer
285. Mr K Lovett, Gay Solidarity Group NGO
286. Mrs M Lukes, ARAFMI NGO
287. Mr D McDonald, Forestry and Mining Employees Union Trade Union
288. Name withheld Carer
289. Mr J McLenaghan, Life Insurance Federation of Australia Prof Assoc
290. Ms S McLoughlin Consumer
291. Mr R Malcolm Concerned Citizen
292. Mrs I Mack Consumer
293. Ms L Macpherson, Family Association for Mental Health Support NGO 
294. Ms M Maher Consumer 
295. Ms B Marks Carer 
296. Mr B Marsh Concerned Citizen 
297. Ms J Martin Concerned Citizen 
298. Ms P Martyn, Mental Health Services North Coast Region, NSW 
Health Department Govt 
299. Name withheld Consumer 
300. Ms C Miller Consumer 

Page 968 Mental Illness Inquiry 

301. Name withheld Carer 
302. Name withheld Consumer
303. Mr A Nettleton Consumer
304. Mrs E Nettleton Carer
305. Ms A Newham, Alliance for the Mentally 111, Australia NGO
306. Mr T Newlands, Manic Depressive Group in the Hunter NGO
307. Mr T Nicholls, GROW NGO
308. Mr E Nimri, Mental Health Co-ordinating Council NGO
309. Ms J Noble Concerned Citizen
310. Mrs H Nolan Consumer
311. NSW Association for Mental Health NGO
312. NSW Health Department Govt
313. Ms L O'Brien, Hornsby Ku-ring-gai Association Action for 
Mental Health NGO
314. Dr P O'Neill Medical Practitioner
315. Mr G Page Concerned Citizen
316. Prof G Parker, Dept of Psychiatry, University of NSW Psychiatrist
317. Mr T Paynter Consumer
318. Mr M Peacock, Country Freedom Group NGO
319. Ms D Peck, GROW, Hunter/Central Coast Region NGO
320. Mr H Peck Concerned Citizen
321. Name withheld Carer
322. Mrs J Pickering Concerned Citizen 
323. Ms M Pinervia, ARAFMI NGO
324. Ms M Podnieks, CENTACARE CRO
325. Ms H Pountney, Association of Self Help Organisations NGO
326. Ms J Prigg Consumer
327. Mr B Rainey Consumer
328. Dr C Reading Psychiatrist
329. Dr J Rey, Rivendell Child Adolescent and Family Psych Services Psychiatrist
330. Ms J Roberts Psychiatric Nurse
331. Mrs M Robinson Consumer
332. Dr S Robinson, Hunter Area Community Mental Health Service Psychiatrist
333. Dr A Rosen, Area Integrated Mental Health Standards Project Psychiatrist
334. Name withheld Consumer
335. Name withheld Carer
336. Dr A Ryan Medical Practitioner
337. Ms J Said, After Care Association of NSW NGO
338. Mr P Scollay Clinical Psychologist
339. Name withheld Carer
340. Name withheld Consumer
341. Mr J She wan Consumer
342. Mr G Shoebridge Consumer
343. Ms J Short Concerned Citizen
344. Ms J Short Carer
345. Ms N Short Carer
346. Mr P Sievert Consumer
347. Prof D Silove, South West Sydney Area Health Service Psychiatrist
348. Mr J Simpson, Croydon Living Skills Centre Govt
349. Mrs P Simpson, ARAFMI NGO
350. Mr D Skinner, Mental Illness and Nervous Disorders Society (MINDS) NGO 

Human Rights and Equal Opportunity Commission Page 969 
 
351.Dr Y Skinner Psychiatrist 
352.Ms M Smith, Depressive & Manic Depressive Association Consumer, NGO
353.Mr B Smout Concerned Citizen
354. Prof J Snowdon, University of NSW, Prince Henry Hospital Psychogeriatrician
355.St Vincent de Paul Society, National Council CRO
356.Mrs J Steel Consumer
357.Name withheld Consumer
358.Name withheld Consumer
359.Ms J Sulima, SOMA, Health Association of Australia NGO
360.Name withheld Carer
361.Mr D Swain, Mental Health Advocacy Service NGO
362.Ms P Taylor Psychiatric Nurse
363. Dr J Thompson, Forensic Study Group, RANZCP Psychiatrist
364.Transitional Enterprises Inc NGO
365.Ms W Turner Concerned Citizen
366.Mr G Udy, Lifeline CRO
367.Mr R Van Wegen, Australian Community Action Network NGO
368.Mr C Vowles, United Nations' Association of Australia NGO
369.Ms M Walton, Complaints Unit, NSW Department of Health Govt
370. Name withheld Consumer
371.Mr R Weaver Concerned Citizen
372.Prof I Webster, NSW Association for Mental Health NGO
373.Ms W Weir Occupational Therapist
374.Mr E Wellman Concerned Citizen
375.Name withheld Carer
376.Ms P Williams Concerned Citizen
377. Ms M Wilson Social Worker
378.Mr N Wilson Concerned Citizen
379.Name withheld Consumer
380.Ms J Woodruff, NSW Women's Co-ordination Unit Govt
381.Mr A York Nurse
382.Mr J Young, Hamilton South Community Group NGO
383.Name withheld Consumer
384.Mr W Zyla, Community Mental Health Services, Orange Govt
385.Name withheld Consumer

Page 970 Mental Illness Inquiry 

QUEENSLAND 
 
386. Mr C Ackerman Concerned Citizen
387. Dr C Alroe Psychiatrist
388. Mr T Atkin, Schizophrenia Fellowship of South Qld NGO
389. Mrs E Bacon Carer
390. Mrs L Bailey Consumer
391. Names withheld Carers
392. Mr R Batt Consumer
393. Mr A Beesley Consumer
394. Mrs H Binns Consumer
395. Name withheld Consumer
396. Mrs J Booth Carer
397. Name withheld Consumer
398. Mr T Breadsell, Concerned Citizens & Supported Accommodation 
Options NGO
399. Mrs M Broad Carer
400. Dr F Bryant, Queensland Country Psychiatrists' Assoc Prof Assoc
401. Mrs F Bubb Consumer
402. Mr & Mrs Burey Carers
403. Ms A Campbell, West Moreton Regional Office, Dept of Health Govt
404. Dr C Cantor, Suicide Research & Prevention Program, Dept 
of Health Govt
405. Mr D Cheetham, Brisbane Manic Depressive Support Group NGO
406. Mr G Christmas, ARAFMI NGO
407. Mr J Clarke, Central Qld Multidisciplinary Psychiatric Team Govt
408. Mr J Cockerill, Public Trust Office Govt
409. Mrs D Conway Consumer
410. Mr N Cunningham Consumer
411. Dr J Cutbush, Queensland Branch, RANZCP Prof Assoc
412. Mr C Davies, Mental Action Group NGO
413. Mrs M Dearer Consumer
414. Ms G Deordas Consumer
415. Mrs C Doherty Carer
416. Mrs A Ellis Carer
417. Prof L Evans, Anxiety Disorder Clinic, University of Queensland Psychiatrist
418. Mrs E Ferriday Consumer
419. Ms C Fischer, Independent Advocacy in the Tropics NGO
420. Mr M Free and Ms H Ravenscroft Psychologists
421. Mr J Fry Consumer 
422. Mr M Galligan Consumer
423. Mr R Garvey Consumer
424. Mrs J Graham Consumer
425. Mrs I Gray Carer
426. The Hon W Goss, Premier Govt
427. Mr B Green, John Oxley Memorial Hospital Social Worker
428. Mr P Gregory, Advocacy for the Aged Association Inc NGO
429. Mrs G Griffiths Consumer
430. Mr J Hammett Concerned Citizen
431. Mr P Halpin Consumer

CLASSIFICATION 

Human Rights and Equal Opportunity Commission Page 971 

432. Mr S Hamlyn-Harris, Legal Aid Office Govt 
433. Ms D Hanson Concerned Citizen
434. Mrs C Healy Consumer
435. Mrs C Healy Carer
436. Sr C Hefferan, St Vincent de Paul Society CRO
437. Ms M Herring, Schizophrenia Fellowship of Nth Qld NGO
438. Mr R Hilsdon, Queensland Deaf Society NGO
439. Mr O Hodgson, Schizophrenia Fellowship NGO
440. Name withheld Carer
441. Name withheld Carer
442. Mrs J Holdway Consumer
443. Mrs P Hutchins, ARAFMI, Sunshine Coast NGO
444. Ms B Innis Social Worker
445. Mrs I Isaacs Carer
446. Prof B James, Director of Psychiatry, lames Cook University 
at Townsville General Hospital Psychiatrist
447. Ms N Jessop, Fortitude Valley Community Mental Health Centre Govt
448. Mr D Jones, Queensland Nurses Union Prof Assoc
449. Mr P Jones, Safe Accommodation For Everyone (SAFE) NGO
450. Ms C Kerr Occupational Therapist
451. Mrs M Kilpatrick Concerned Citizen
452. Ms A Lamprecht Carer
453. Ms P Lang, Friends for the Mentally Ill NGO
454. Prof J Lawrence, University of Queensland at Royal Brisbane Hospital Psychiatrist
455. Mrs J Lawrence Carer
456. Ms E Leah Consumer
457. Ms K Lean Consumer
458. Names withheld Carers
459. Ms H Low Consumer
460. Ms M Lucas, GROW NGO
461. Name withheld Psychiatric Nurse
462. Name withheld Consumer
463. Mr D McLaughlin, ARAFMI NGO
464. Ms J McLaughlin, ARAFMI NGO
465. Mrs S McLoughlin Consumer
466. Mr G McMahon Consumer
467. Ms J Magub, Qld Association for Mental Health NGO
468. Names withheld Carers
469. Ms M Makin Consumer
470. Mr D Maroevic, Migrant Resource Centre NGO
471. Ms C Mercer, Marlish Aftercare Home Private Hostel
472. Mrs V Meyers Carer
473. Miami Special Interest Mental Health Group NGO
474. Mr W Milfull Consumer
475. Ms B Miller, Aboriginal Co-ordinating Council NGO
476. Mrs M Milne Consumer
477. Mrs J Muir Carer
478. Mrs A Miscovich Carer
479. Mrs Y Murray Carer
480. Mrs J Nicol, Schizophrenia Fellowship NGO
481. Mrs J Nicol Carer

Page 972 Mental Illness Inquiry 

482.Mr P O'Brien, Brisbane Psychiatric Social Workers Interest Group Prof Assoc
483.Mr V O'Donnell, Roma & District Community Support Association  NGO 
484.Mrs M O'Neill Consumer
485.Mrs K Payne  Carer 
486.Ms V Peisker Consumer 
487.Mrs F Pownall, Caring Committee for the Mentally 111 NGO 
488.Mr E Priddle Psychiatric Nurse 
489. Queensland Government Govt 
490. Mr J Quinn Psychiatric Nurse 
491. Mr J Raine Carer
492. Ms S Raine  Carer
493. Mr C Regan  Consumer
494. Name withheld  Carer 
495. Mrs J Rocker Carer   
496. Mrs J Roy Carer  
497. Mr J Russell Concerned Citizen
498. Name withheld Consumer
499. Mr R Schluter Consumer
500. Ms M Schroder, Queensland Advocacy Inc NGO  
501.Mr N Segal Carer
502.Mrs H Selinger Carer
503. Mr J Skelton, SOMA NGO   
504. Name withheld Consumer 
505. Mr H Smith Consumer 
506. Fr J Smith, Catholic Psychiatric Pastoral Care CRO
507. Name withheld Carer
508. Mr P Stanley, Qld Dept of Health  Govt 
509. Mrs L Teallaj Consumer
510. Mrs M Tebbitt Carer 
511. Name withheld  Consumer
512. Mrs M Thomas Carer 
513. Mr N Thompson Consumer
514. Ms S Tonkin, Queensland Council for Civil Liberties NGO
515. Dr P Tucker Psychiatrist 
516. Name withheld  Carer
517. Dr A Urquhart, Director, Psychiatry, Mater Children's Hospital Psychiatrist   
518. Mrs M Vance Consumer
519. Mr T Wade, Australian National Association for Mental Health NGO
520. Ms S Wadley, National Carers' Association NGO 
521. Mrs B Wainman Consumer
522. Mrs M Walsh, Australian Parent Advocacy NGO 
523. Rev C Ware Carer 
524. Mr D Warth Consumer 
525. Dr P Watson Anthropologist 
526. Names withheld Carers 
527. Ms R Westbrook  Consumer  
528. Mrs D Wheeler Carer
529. Mrs M Whiting  Carer
530. Mrs E Wilcox Carer

Human Rights and Equal Opportunity Commission Page 973 

531. Ms S Wilkie, Field Worker, Aboriginal & Islander Community 
Health Service Govt 
532. Name withheld Consumer 
533. Mr R Williams, Queensland Wattle League for the Disabled NGO 
534. Name withheld Psychiatric Nurse 

Page 974 Mental Illness Inquiry 

WESTERN AUSTRALIA 
NAME CLASSIFICATION 
 
535.Dr L Achimovich, Fremantle Hospital Psychiatrist 
536.Name withheld Consumer 
537. Ms T Antill, Psychiatric Occupational Therapists' Group, 
Osborne Park Hospital Prof Assoc
538.Mr M Austen  Consumer
539.Mrs Laylmore  Carer
540.Mrs M Bellman  Consumer 
541.Mrs H Berill Consumer 
542.Ms N Bertinshaw, Health Department, South West Region Govt 
543. Dr G Boranga, Multicultural Psychiatric Centre Psychiatrist 
544. Mrs D Borlase Consumer
545. Ms E Brackenreg, Health Department, North East Metropolitan Region  Govt 
546. Name withheld Advocate 
547. Mrs H Buckley Carer 
548. Mr W Burong Carer
549. Ms R Butcher  Consumer 
550. Mrs H Byles Drage Psychologist
551. Mrs P Carberry, ARAFMI  NGO 
552. Mr F Collard Concerned Citizen 
553.Mr C Coopes, Accommodation Support Program,WA Health Dept Govt
553a. Mr G Covich, Schizophrenia Fellowship  NGO 
554.Sr B Daly Prison Visitor
555.Name withheld  Carer 
556Name withheld Carer
557. Ms P Dudgeon  Psychologist
558. Ms J Dye, Milgrey House  NGO 
559. Mr B Edwards Consumer 
560. Mrs M English Carer 
561. Ms D Fergusson-Stewart, Caring Services, Anglican Homes CRO 
562. Mr H French Concerned Citizen 
563. Mr J Gardiner Clinical Psychologist
564. Ms J Geary  Consumer
565. Dr J Godfrey  Carer 
566. Mr B Gooley Concerned Citizen
567. Mr E Gosney Consumer
568. Mr N Gregory, Australian Congress of Mental Health Nurses Prof Assoc
569. Mr P Hammond Concerned Citizen
570. Mr G Hancy Concerned Citizen
571. Ms M Harries, Australian Association of Social Workers Prof Assoc
572. Ms B Harris, Emmanuel Centrecare CRO
573. Ms E Hayden, Southern Aboriginal Corporation NGO
574. Mr R Hetherington Concerned Citizen
575. Dr Neville Hills Psychogeriatrician
576. Name withheld Consumer
577. Dr D Jacobs, RANZCP Prof Assoc
578, Ms M Johnson, Drug Adverse Reaction Information Centre NGO

Human Rights and Equal Opportunity Commission Page 975 

579.Name withheld Consumer
580.Name withheld Psychiatric Nurse
581.Ms C Kneebone, Albany Schizophrenia Fellowship NGO
582. Dr S Kostov, Multicultural Psychiatric Centre Psychiatrist
583. Ms M Leach, Outcare, Civil Rehabilitation Council of WA NGO
584.Name withheld Consumer
585.Dr J Leavesley, Heathcote Board of Visitors ISOH
586.Ms E Lenz, Resource Centre for Personal Development NGO
587.Dr John Lindsay, Former Director, Ward 10B, Townsville Psychiatrist
588.Dr J Lister Psychiatrist
589.Dr D Lord, RANZCP Prof Assoc
590.Mr R Mace Concerned Citizen
591.Ms L MacLeod, WA Psychiatric Nurses' Association Prof Assoc
592.Ms M MacPherson Social Worker
593.Ms L Maddison Psychiatric Nurse
594.Mr J Manners, Institute of Private Clinical Psychologists Prof Assoc
595.Mr J and Mrs P Marsh Carers
596.Name withheld Consumer
597.Mr N Mhen Psychiatric Nurse 
598.Mr W O'Brien Psychiatric Nurse
599.June O'Connor Centre NGO
600.Ms B Other-Gee, WACOSS NGO
601.Name withheld Consumer
602.Names withheld Carers
603.Ms V Rowney, Country Women's Association of WA NGO
604.Mrs I Sales Consumer
605.Name withheld Carer
606.Name withheld Consumer
607.Mrs H Sharp, Albany Schizophrenia Fellowship NGO
608.Mr N Sharp Concerned Citizen
609.Ms J Sinclair Welfare Officer
610.Dr D Smith, South-West Health Region, WA Health Department Psychiatrist
611.Name withheld Consumer
612.Ms P Stone Social Worker
613.Name withheld Consumer
614.Mr P Thompson Carer
615.Mr J & Mrs J Tracey Carers
616.Ms T Vanderwal, Mentally Ill Need Defending (MIND) NGO
617.Ms A Wearne Social worker, Academic 
618.Ms C White Concerned Citizen 
619.Ms J Winch, Marr Mooditj Foundation, Aboriginal Health Worker College Academic
620.Mr K Wyatt, Aboriginal Health Policy Unit, Health Dept of WA Govt
621.Ms C O'Farrell, Regional Director, Kimberley Health Region Govt
622.Mr P O'Hara, Social Work Supervisor, Graylands Hospital Social Worker
623.Ms B Pondaag, Pilbara Region, WA Health Department Govt
624.Name Withheld Consumer 
625.Western Australian Government Govt
626.The Hon Keith Wilson MLA, WA Minister for Health Govt

Page 976 Mental Illness Inquiry 

NORTHERN TERRITORY 
NAME 
627. Mr J Arrand, NT Council on the Ageing NGO
628. Ms S Capes Consumer
629. Ms E Carter, Central Australian Aboriginal Congress NGO
630. Mrs M Crabbe Concerned Citizen
631. Ms D Hall, NT Dept of Health and Community Services Govt
632. Ms J Harrison, Central Australian Advocacy Service NGO
633. Dept of Health and Community Services Govt
634. Name withheld Carer
635. Mr J Hopkins, Disability Services of Central Australia NGO
636. Ms S de la Hunt, Commonwealth Rehabilitation Service Govt
637. Name withheld Consumer
638. Mr J Lawrence, North Australian Aboriginal Legal Service NGO
639. Mr W McMahon, NT Association for Mental Health NGO
640. Mr W McMahon, St Vincent de Paul Society NGO
641. Ms A Mitchell Social Worker
642. Mr G Norris Psychiatric Nurse
643. Mr M Owen, Miwatj Health Aboriginal Corporation NGO
644. Mr F Panaia, Secretary, NT Assoc for Mental Health NGO
645. Ms G Payne, GROW NGO
646. Ms J Pendlebury, Dawn House Women's Shelter NGO
647. Mrs M Pere Carer
648. The Hon M Perron MP, Chief Minister Govt
649. Name withheld Consumer CLASSIFICATION 

650. Ms B Shaw, Tangentyere Council NGO
651. Dr P Thorn Medical Practitioner
652. Mr J Torkington Concerned Citizen
653. Dr B Tyler, NT Mental Health Association NGO
654. Mr R Wesley-Smith Concerned Citizen


Human Rights and Equal Opportunity Commission Page 977 

ACT 
NAME 
655. ACT Government Govt
656. Mr B Aldcroft, Ainslie Village NGO
657. Dr M Anderson 
658. Mr B Bailey, Acting Community Advocate 
659. Mr L Barr 
660. Name withheld 
661. Names withheld 
662. Ms J Braithwaite, ACROD 
663. Ms G Burnett 
664. Name withheld 
665. Mr P Chivers, Adult Corrective Services, ACT Housing and Community Services 
Bureau Govt
666. Name withheld Consumer 
667. Name withheld Concerned Citizen 
668. Ms K Fryar, Legal Aid Office Govt
669. Names withheld Carers
670. Ms D Gordon, Australian Association of Social Workers 
671. Name withheld Consumer Prof Assoc
672. Commonwealth Department of Health, Housing and Community Services Govt
673. Mr P Hinchliffe, Ainslie Village Residents Association NGO
674. Mr B FAnson, Mental Health Foundation NGO 
675. Dr T Jorm, Social Psychiatry Research Unit, ANU and NHMRC Research Psychiatrist
676. Mr B Lloyd Law Student
677. Mr P Lowe Concerned Citizen
678. Ms P Lowrey, Mental Health Task Force, Consumers' Health Forum NGO
679. Mr D Mclver Consumer
680. Name withheld Carer 
681. Ms R Nairn, Child and Adolescent Unit, ACT Mental Health Services Govt
682. Ms L O'Donoghue, Citizens' Committee on Human Rights NGO
683. Dr S Rosenman, Director of Psychiatry, Woden Valley Hospital Psychiatrist
684. Mr B Shaw, Consumers' Health Forum NGO
685. Ms L Steeper, ACTCOSS Mental Health Task Force NGO
686. Ms C Stuart Legal Researcher
687. Ms K Sutinen, Self-Supporting Schizophrenia Sufferers NGO
688. Mr J Templeman Carer
689. Name withheld Consumer
690. Name withheld Consumer
 

??Concerned Citizen Govt Consumer Carer Carers NGO Consumer 
Carer

Page 978 Mental Illness Inquiry 


SOUTH AUSTRALIA 
NAME 
691. Ms J Anderson, SA Association of Mental Health Social 
Workers Prof Assoc 
692. Ms B Arnold, Community Accommodation Support Services Govt
693. Australian Nursing Federation Prof Assoc 
694. Name withheld Consumer 
695. Mr J Blassky Concerned Citizen 
696. Ms E Bleby Social Worker 
697. Mr R Bruggeman, Intellectual Disability Services Council NGO
698. Name withheld Carer
699. Ms C Caust, Child and Adolescent Mental Health Services Govt
700. Mr R Chapman, Community Accommodation Support Service Govt
701. Mr A Cielens Concerned Citizen
702. Dr J Clayer, SA Health Commission Mental Health Research & Evaluation Centre Govt
703. Mr D Crawley Social Worker 
704. Dr A Czechowicz, Carramar Clinic Psychiatrist
705. Ms L Dalston, Mental Health Association and Resource Centre NGO
706. Ms W Danforth, Murray Mallee Health & Social Welfare Council NGO
707. Ms P Donoughue Consumer
708. Mr M Dougherty, Housing and Disability Forum NGO
709. Mr D Dowling Consumer
710. Ms R Downing, Anorexia & Bulimia Nervosa Assoc NGO
711. Ms A Draper, Management Assessment Panel for Behaviourally Disordered Persons Govt
712. Ms M Dugon, Disability Complaints Service NGO
713. Mr K Duke, Community Accommodation Support Service Govt
714. Name withheld Consumer
715. Dr R Elzinga, Hillcrest Hospital Psychiatrist
716. Ms B Fox, Agoraphobia Assoc of SA NGO
717. Ms S Fryar Concerned Citizen 
718. Name withheld Consumer
719. Ms T Hart, Community Accommodation Support Service Govt
720. Ms A Holmes Social Worker
721. Mr R Holmes Student
722. Irene Women's Shelter NGO
723. Mr L James Concerned Citizen
724. Dr N James, Chief Executive Officer, Hillcrest Hospital Govt
725. Mr P John, Invicta Sheltered Workshops Private Establishment 
726. Mr D Jones Consumer
727. Name withheld Consumer
728. Ms B Kilernen Concerned Citizen
729. Name withheld Consumer
730. Prof R Kosky, University of Adelaide at Adelaide Children's Hospital Psychiatrist
731. Name withheld Consumer
732. Ms B Lazarus, Judith House NGO
733. Mr H Lindquist Consumer
734. Mr H Lucke, Semaphore Residents Assoc NGO

Human Rights and Equal Opportunity Commission Page 979 

735.Ms S Madex Consumer 
736.Dr G Martin, Southern Child and Adolescent Mental Health Service Psychiatrist
737.Sr J Mead, Adelaide Day Centre for Homeless Persons CRO
738.Mr D Meldrum, Mental Health Unit, SA Health Commission Govt 
739.Mr L Mell Academic
740.Mr D Neville Consumer
741.Panic Anxiety Disorder Assoc of SA NGO 
742.Ms S Pearce, Whyalla Hospital Nurse 
743.Mr I Pitcher Concerned Citizen
744.Mr M Potter Concerned Citizen 
745.Dr R Powrie Concerned Citizen 
746.Mr K Rainsford, GROW NGO
747.Mr R Rana Concerned Citizen 
748.Name withheld Consumer
749.Mrs J Sherry Concerned Citizen 
750.Mr C Slocabe, Obsessive Compulsive Neurosis Support Group NGO
751.Name withheld Consumer
752.Name withheld Consumer
753.Name withheld Carer 
754.Name withheld Carer
755.Name withheld Carer
756. Mrs F Towill Consumer
757.Mrs I Towler, Schizophrenia Fellowship of SA NGO
758.Mrs R Tucker Carer
759.Ms M Van Der Byl Academic
760.T J Wayne Consumer
761.Dr C Wilson, National Police Research Unit Govt 
762. Mr R Woon, Self-Help Mood Disturbance Prevention (MDP) NGO
763. Ms D Wright, Central Clinic, Port Augusta Govt

Page 980 Mental Illness Inquiry 

TASMANIA 
NAME CLASSIFICATION 
764. Dr T Avery Psychiatrist
765. Name withheld Psychiatric Nurse
766. Ms P Berkery, Domestic Violence Action Group NGO
767. Mr T Blackwell, Co-ordinator, The Link, Youth Health Service NGO
768. Ms M Blackwood, Southern Region Mental Health Service, Department of Health Govt
769. Name withheld Carer
770. Ms P Bourke, GROW NGO 
771. Mrs V Bradley Carer
772. Name withheld Carer
773. Mr C de Bills Consumer
774. Dr N Cochrane, Department of Health Psychologist
775. Ms T Evans, Domestic Violence Action Group NGO
776. Ms M Fawdry, Tas Community Health Association Psychiatric Nurse
777. Name withheld Consumer
778. Ms S Goiser Interpreter 
779. Ms J Harwood Carer
780. Ms E Holmes, Migrant Resource Centre NGO
781. Mr P Johnson, ARAFMI NGO
782. Names withheld Concerned Citizens 
783. Prof I Jones, Professor of Psychiatry, University of Tasmania Psychiatrist 
784. Dr W Kerr, Director of Psychiatric Services, Northwest Region Govt
785. Mr F Kitson Concerned Citizen 
786. Mrs N Kuilenburg, Jireh House Assoc NGO
787. Ms R Laver, Australian Psychological Society Prof Assoc 
788. Mr J Leary, Department of Health Govt 
789. Name withheld Consumer
790. Ms K Linahan, Migrant Resource Centre NGO
791. Name withheld Carer
792. Ms J McCulloch Itinerant Teacher 
793. Ms G May Community Worker 
794. Name withheld Carer
795. Ms M Nielsen, Community Hostels Assoc NGO
796. Dr R Pargiter, Chairman, Ethics Committee, RANZCP Prof Assoc 
797. Mr S Pinkus, Clare House Child and Adolescent Mental 
Health Service Govt
798. Psychiatric Services Division, Tasmanian Health Dept Govt
800. Dr S Pridmore, Psychiatric Services Division, Department 
of Health Govt
801. Mr R Redom, Australian National Assoc for Mental Health NGO 
802. Name withheld Carer 
803. Mr I Ribic Consumer 
804. Dr M Roberts Psychiatrist 
805. Name withheld Carer 
806. Ms K Stanick Social Worker 
807. Ms J Tanner Youth Worker 
808. Name withheld Consumer

Human Rights and Equal Opportunity Commission Page 981 

809. Tasmanian Government Govt 
810. Mrs S Taylor Social Worker 
811. Dr J Tooth, President, Alzheimer's Assoc Psychogeriatrician 
812. Name withheld Consumer 

Page 982 Mental Illness Inquiry 

MISCELLANEOUS 
NAME CLASSIFICATION 
813. Alison Carer 
814. Anonymous Consumer 
815. Anonymous Consumer 
816. Anonymous Carer 
817. Anonymous Consumer 
818. Anonymous - SA Consumer 
819. Anonymous - TAS Consumer 
820. Anonymous - WA Consumer 
821. Anonymous - WA Carer 
822. Mr T Avery NSW 
Concerned Citizen 
823. Mr M Carter Concerned Citizen 
824. People Against Power Abuse (Vic) NGO 
825. Mr G Matena Social Worker 
826. Name withheld Consumer 

Human Rights and Equal Opportunity Commission Page 983 


APPENDIX 3 

FACILITIES VISITED BY INQUIRY 

All hospitals listed in this appendix are psychiatric hospitals. 
Psychiatric wards or units, however, are located in general hospitals. 

July 1991 
Newcastle 
• Morisset Hospital 
• Banksia House Rehabilitation Program 
• Lake Macquarie Community Mental Health Team 
• Residential Services Team, Mayfield 
Orange 
• Bloomfield Hospital 
• Arcadia House Community Mental Health Service 
• SHIPS Program (Satellite Housing Integrated Programmed 
Support): Endeavour House and Kallara 

August 1991 
Townsville 
• Psychiatric Unit (formerly Ward 10B), Townsville General 
Hospital 
• Vincent Community Mental Health Centre 
Brisbane 
• Royal Brisbane Hospital: Ward 3A and Ward B 
• Rosemount Hospital 
• John Oxley Hospital 
• Wolston Park Hospital 
October 1991 
Adelaide 
• Hillcrest Hospital 
• James Nash House (Forensic Unit) 
• Glenside Hospital 
• Southern Child and Adolescent Mental Health Service 
(CAMHS), Flinders Medical Centre 

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November 1991 Hobart 

Royal Derwent Hospital 

Risdon Prison Forensic Unit 

Flagstaff Gully Dementia Home 

Richmond Fellowship 

Peacock Hospital (Residential, Day and Respite Care) 

February 1992 Perth: 

Lefroy Hostel (Dementia Care) 

Graylands Hospital 

Heathcote Hospital 

Royal Perth Hospital Psychiatric Unit 
Fremantle Hospital 

Fremantle Clinic 

Hillview Terrace Child and Family Clinic 

Hillview Terrace Hospital 

Selby Lodge 

Avro Clinic 

June O'Connor Drop-In Centre 

Albany: Milgrey House 

May 1992 Sydney: Arndell Child and Adolescent Unit, Macquarie Hospital 

July 1992 
Darwin: Psychiatric Ward, Royal Darwin Hospital 

Sydney: Dementia Unit, Rozelle Hospital 


Human Rights and Equal Opportunity Commission Page 985 


APPENDIX 4 

DECLARATION ON THE RIGHTS OF DISABLED PERSONS 

Proclaimed by General Assembly Resolution 3447 (XXX) of 9 December 1975 

The General Assembly 

Mindful of the pledge made by Member States, under the Charter of the United 
Nations; to take joint and separate action in co-operation with the Organisation 
to promote higher standards of living, full employment and conditions of 
economic and social progress and development, 

Reaffirming its faith in human rights and fundamental freedoms and in the 
principles of peace, of the dignity and worth of the human person and of social 
justice proclaimed in the Charter, 

Recalling the principles of the Universal Declaration of Human Rights, the 
International Covenants on Human Rights, the Declaration of the Rights of the 
Child and the Declaration on the Rights of Mentally Retarded Persons, as well 
as the standards already set for social progress in the constitutions, 
conventions, recommendations and resolutions of the International Labour 
Organisation, the United Nations Educational, Scientific and Cultural
 Organisation, the World Health Organisation, the United Nations Children's 
Fund and other organisations concerned, 

Recalling also Economic and Social Council resolution 1921 (LVIII) of 6 May 
1975 on the prevention of disability and the rehabilitation of disabled persons, 

Emphasising that the Declaration on Social Progress and Development has 
proclaimed the necessity of protecting the rights and assuring the welfare and 
rehabilitation of the physically and mentally disadvantaged, 

Bearing in mind the. necessity of preventing physical and mental disabilities
 and of assisting disabled persons to develop their abilities in the most
 varied fields of activities and of promoting their integration as far as 
possible in normal life, 

Aware that certain countries, at their present stage of development, can devote 
only limited efforts to this end, 

Page 986 Mental Illness Inquiry 

Proclaims this Declaration on the Rights of Disabled Persons and calls for 

national and international action to ensure that it will be used as a common 

basis and frame of reference for the protection of these rights: 

1 The term 'disabled person' means any person unable to ensure by himself 
or herself, wholly or partly, the necessities of a normal individual and/or 
social life, as a result of deficiency, either congenital or not, in his or her 
physical or mental capabilities. 

2 Disabled persons shall enjoy all the rights set forth in this Declaration. 
These rights shall be granted to all disabled persons without any exception 
whatsoever and without distinction or discrimination on the basis of race, 
colour, sex, language, religion, political or other opinions, national or 
social origin, state of wealth, birth or any other situation applying either 
to the disabled person himself or herself or to his or her family. 

3 Disabled persons have the inherent right to respect for their human 
dignity. Disabled persons, whatever the origin, nature and seriousness 
of their handicaps and disabilities, have the same fundamental rights as 
their fellow-citizens of the same age, which implies first and foremost the 
right to enjoy a decent life, as normal and full as possible. 

4 Disabled persons have the same civil and political rights as other human 
beings; paragraph 7 of the Declaration on the Rights of Mentally 
Retarded Persons applies to any possible limitation or suppression of 
those rights for mentally disabled persons. 

5 Disabled persons are entitled to the measures designed to enable them to 
become as self-reliant as possible. 

6 Disabled persons have the right to medical, psychological and functional 
treatment, including prosthetic and orthotic appliances, to medical and 
social rehabilitation, education, vocational training and rehabilitation, aid, 
counselling, placement services and other services which will enable them 
to develop their capabilities and skills to the maximum and will hasten the 
process of their social integration or reintegration. 

7 Disabled persons have the right to economic and social security and to a 
decent level of living. They have the right, according to their capabilities, 
to secure and retain employment or to engage in a useful, productive 
and remunerative occupation and to join trade unions. 

Human Rights and Equal Opportunity Commission Page 987 

8 Disabled persons are entitled to have their special needs taken into 
consideration at all stages of economic and social planning. 

9 Disabled persons have the right to live with their families or with foster 
parents and to participate in all social, creative or recreational activities. 
No disabled person shall be subjected, as far as his or her residence is 
concerned, to differential treatment other than that required by his or her 
condition or by the improvement which he or she may derive therefrom. 
If the stay of a disabled person in a specialised establishment is indispensable, 
the environment and living conditions therein shall be as close as 
possible to those of the normal life of a person of his or her age. 

10 Disabled persons shall be protected against all exploitation, all regulations 
and all treatment of a discriminatory, abusive or degrading nature. 

11 Disabled persons shall be able to avail themselves of qualified legal aid 
when such aid proves indispensable for the protection of their persons and 
property. If judicial proceedings are instituted against them, the legal 
procedure applied shall take their physical and mental condition fully into 
account. 

12 Organisations of disabled persons may be usefully consulted in all matters 
regarding the rights of disabled persons. 

13 Disabled persons, their families and communities shall be fully informed, 
by all appropriate means, of the rights contained in this Declaration. 

Page 988 Mental Illness Inquiry 



APPENDIX 5 

PRINCIPLES FOR THE PROTECTION OF PERSONS WITH MENTAL ILLNESS AND FOR THE 
IMPROVEMENT OF MENTAL HEALTH CARE 

APPLICATION 

These principles shall be applied without discrimination of any kind such as on 
grounds of disability, race, colour, sex, language, religion, political or other 
opinion, national, ethnic or social origin, legal or social status, age,
 property or birth. 

DEFINITIONS 

In these Principles: 

'counsel' means a legal or other qualified representative; 

'independent authority' means a competent and independent authority 
prescribed by domestic law; 

'mental health care' includes analysis and diagnosis of a person's 
mental condition, and treatment, care and rehabilitation for a mental 
illness or suspected mental illness; 

'mental health facility' means any establishment, or any unit of an 
establishment, which as its primary function provides mental health 
care; 

'mental health practitioner' means a medical doctor, clinical psychologist, 
nurse, social worker or other appropriately trained and qualified 
person with specific skills relevant to mental health care; 

'patient' means a person receiving mental health care and includes all 
persons who are admitted to a mental health facility; 

'personal representative' means a person charged by law with the duty 
of representing a patient's interests in any specified respect or of 
exercising specified rights on the patient's behalf, and includes the 
parent or legal guardian of a minor unless otherwise provided by 
domestic law; 

Human Rights and Equal Opportunity Commission Page 989 

'the review body' means the body established in accordance with 
Principle 17 to review the involuntary admission or retention of a 
patient in a mental health facility. 

GENERAL LIMITATION CLAUSE 

The exercise of the rights set forth in these Principles may be subject only to 
such limitations as are prescribed by law and are necessary to protect the health 
or safety of the person concerned or of others or otherwise to protect public 
safety, order, health or morals or the fundamental rights and freedoms of 
others. 

Principle 1 
FUNDAMENTAL FREEDOMS AND BASIC RIGHTS 

1. All persons have the right to the best available mental health care, which 
shall be part of the health and social care system. 
2. All persons with a mental illness, or who are being treated as such 
persons, shall be treated with humanity and respect for the inherent 
dignity of the human person. 
3. All persons with a mental illness, or who are being treated as such 
persons, have the right to protection from economic, sexual and other 
forms of exploitation, physical or other abuse and degrading treatment. 
4. There shall be no discrimination on the grounds of mental illness. 
'Discrimination' means any distinction, exclusion or preference that has 
the effect of nullifying or impairing equal enjoyment of rights. Special 
measures solely to protect the rights, or secure the advancement, of 
persons with mental illness shall not be deemed to be discriminatory. 
Discrimination does not include any distinction, exclusion or preference 
undertaken in accordance with the provisions of these Principles and 
necessary to protect the human rights of a person with a mental illness or 
of other individuals. 
5. Every person with a mental illness shall have the right to exercise all 
civil, political, economic, social and cultural rights as recognised in the 
Universal Declaration of Human Rights, the International Covenant on 
Economic, Social and Cultural Rights, the International Covenant on Civil 
and Political Rights and in other relevant instruments such as the 

Page 990 Mental Illness Inquiry 


Declaration on the Rights of Disabled Persons and the Body of Principles 
for the Protection of All Persons under Any Form of Detention or 
Imprisonment. 

6. Any decision that, by reason of his or her mental illness, a person lacks 
legal capacity, and any decision that, in consequence of such incapacity, 
a personal representative shall be appointed, shall be made only after a 
fair hearing by an independent and impartial tribunal established by 
domestic law. The person whose capacity is in issue shall be entitled to 
be represented by a counsel. If the person whose capacity is in issue does 
not himself or herself secure such representation it shall be made 
available without payment by that person to the extent that he or she does 
not have sufficient means to pay for it. The counsel shall not in the same 
proceedings represent a mental health facility or its personnel and shall 
not also represent a member of the family of the person whose capacity 
is in issue unless the tribunal is satisfied that there is no conflict of 
interest. Decisions regarding capacity and the need for a personal 
representative shall be reviewed at reasonable intervals prescribed by 
domestic law. The person whose capacity is in issue, his or her personal 
representative, if any, and any other interested person shall have the right 
to appeal to a higher court against any such decision. 
7. Where a court or other competent tribunal finds that a person with mental 
illness is unable to manage his or her own affairs, measures shall be 
taken, so far as is necessary and appropriate to that person's condition, 
to ensure the protection of his or her interests. 

Principle 2 
PROTECTION OF MINORS 

Special care should be given within the purposes of these Principles and within 
the context of domestic law relating to the protection of minors to protect the 
rights of minors, including, if necessary, the appointment of a personal 
representative other than a family member. 

Principle 3 
LIFE IN THE COMMUNITY 

Every person with a mental illness shall have the right to live and work, as far 
as possible, in the community. 

Human Rights and Equal Opportunity Commission Page 991 

Principle 4 
DETERMINATION OF MENTAL ILLNESS 

1. A determination that a person has a mental illness shall be made in 
accordance with internationally accepted medical standards. 
2. A determination of mental illness shall never be made on the basis of 
political, economic or social status, or membership of a cultural, racial 
or religious group, or any other reason not directly relevant to mental 
health status. 
3. Family or professional conflict, or non-conformity with moral, social, 
cultural or political values or religious beliefs prevailing in a person's 
community, shall never be a determining factor in diagnosing mental 
illness. 
4. A background of past treatment or hospitalisation as a patient shall not of 
itself justify any present or future determination of mental illness. 
5. No person or authority shall classify a person as having, or otherwise 
indicate that a person has, a mental illness except for purposes directly 
relating to mental illness or the consequences of mental illness. 

Principle 5 
MEDICAL EXAMINATION 

No person shall be compelled to undergo medical examination with a view to 
determining whether or not he or she has a mental illness except in accordance 
with a procedure authorised by domestic law. 

Principle 6 
CONFIDENTIALITY 

The right of confidentiality of information concerning all persons to whom 
these Principles apply shall be respected. 

Page 992 Mental Illness Inquiry 

Principle 7 
ROLE OF COMMUNITY AND CULTURE 

1. Every patient shall have the right to be treated and cared for, as far as 
possible, in the community in which he or she lives. 
2. Where treatment takes place in a mental health facility, a patient shall 
have the right, whenever possible, to be treated near his or her home or 
the home of his or her relatives or friends and shall have the right to 
return to the community as soon as possible. 
3. Every patient shall have the right to treatment suited to his or her cultural 
background. 

Principle 8 
STANDARDS OF CARE 

1. Every patient shall have the right to receive such health and social care 
as is appropriate to his or her health needs, and is entitled to care and 
treatment in accordance with the same standards as other ill persons. 
2. Every patient shall be protected from harm, including unjustified 
medication, abuse by other patients, staff or others or other acts causing 
mental distress or physical discomfort. 

Principle 9 
TREATMENT 

1. Every patient shall have the right to be treated in the least restrictive 
environment and with the least restrictive or intrusive treatment appropriate 
to the patient's health needs and the need to protect the physical safety 
of others. 
2. The treatment and care of every patient shall be based on an individually 
prescribed plan, discussed with the patient, reviewed regularly, revised 
as necessary and provided by qualified professional staff. 

Human Rights and Equal Opportunity Commission Page 993 

3. Mental health care shall always be provided in accordance with applicable 
standards of ethics for mental health practitioners, including internationally 
accepted standards such as the Principles of Medical Ethics adopted by 
the United Nations General Assembly. Mental health knowledge and skills 
shall never be abused. 
4. The treatment of every patient shall be directed towards preserving and 
enhancing personal autonomy. 
Principle 10 

MEDICATION 

1. Medication shall meet the best health needs of the patient and shall be 
given to a patient only for therapeutic or diagnostic purposes and shall 
never be administered as a punishment, or for the convenience of others. 
Subject to the provisions of paragraph 15 of Principle 11, mental health 
practitioners shall only administer medication of known or demonstrated 
efficacy. 
2. All medication shall be prescribed by a mental health practitioner 
authorised by law and shall be recorded in the patient's records. 

Principle 11 
CONSENT TO TREATMENT 

1. No treatment shall be given to a patient without his or her informed 
consent, except as provided for in paragraphs 6, 7, 8, 13 and 15. 
2. Informed consent is consent obtained freely without threats or improper 
inducements after appropriate disclosure to the patient of adequate and 
understandable information in a form and language understood by the 
patient on: 
(a) The diagnostic assessment; 
(b) The purpose, method, likely duration and expected benefit of the 
proposed treatment; 
(c) Alternative modes of treatment, including those less intrusive; and 
Page 994 Mental Illness Inquiry 

(d) Possible pain or discomfort, risks and side-effects of the proposed 
treatment. 
3. A patient may request the presence of a person or persons of the patient's 
choosing during the procedure for granting consent. 
4. A patient has the right to refuse or stop treatment except as provided for 
in paragraphs 6, 7, 8, 13 and 15. The consequences of refusing or 
stopping treatment must be explained to the patient. 
5. A patient shall never be invited or induced to waive the right to informed 
consent. If the patient should seek to do so, it shall be explained to the 
patient that the treatment cannot be given without informed consent. 
6. Except as provided in paragraphs 7, 8, 12, 13, 14 and 15 a proposed plan 
of treatment may be given to a patient without a patient's informed 
consent if the following conditions are satisfied: 
(a) The patient is, at the relevant time, held as an involuntary patient; 
(b) An independent authority, having in its possession all relevant 
information, including the information specified in paragraph 2, is 
satisfied that, at the relevant time, the patient lacks the capacity to 
give or withhold informed consent to the proposed plan of treatment 
or, if domestic legislation so provides, that, having regard to the 
patient's own safety or the safety of others, the patient unreasonably 
withholds such consent; and 
(c) The independent authority is satisfied that the proposed plan of 
treatment is in the best interests of the patient's health needs. 
7. Paragraph 6 does not apply to a patient with a personal representative 
empowered by law to consent to treatment for the patient; but except as 
provided in paragraphs 12, 13, 14 and 15 treatment may be given to such 
a patient without his or her informed consent if the personal representative, 
having been given the information described in paragraph 2, 
consents on the patient's behalf. 
8. Except as provided in paragraphs 12, 13, 14 and 15 treatment may also 
be given to any patient without the patient's informed consent if a 
qualified mental health practitioner authorised by law determines that it 
is urgently necessary in order to prevent immediate or imminent harm to 

Human Rights and Equal Opportunity Commission Page 995 

the patient or to other persons. Such treatment shall not be prolonged 
beyond the period which is strictly necessary for this purpose. 

9. Where any treatment is authorised without the patient's informed consent, 
every effort shall nevertheless be made to inform the patient about the 
nature of the treatment and any possible alternatives, and to involve the 
patient as far as practicable in the development of the treatment plan. 
10. All treatment shall be immediately recorded in the patient's medical 
records, with an indication of whether involuntary or voluntary. 
11. Physical restraint or involuntary seclusion of a patient shall not be 
employed except in accordance with the officially approved procedures 
of the mental health facility and only when it is the only means available 
to prevent immediate or imminent harm to the patient or others. It shall 
not be prolonged beyond the period which is strictly necessary for this 
purpose. All instances of physical restraint or involuntary seclusion, the 
reasons for them, and their nature and extent shall be recorded in the 
patient's medical record. A patient who is restrained or secluded shall be 
kept under humane conditions and be under the care and close and regular 
supervision of qualified members of the staff. A personal representative, 
if any and if relevant, shall be given prompt notice of any physical 
restraint or involuntary seclusion of the patient. 
12. Sterilisation shall never be carried out as a treatment for mental illness. 
13. A major medical or surgical procedure may be carried out on a person 
with mental illness only where it is permitted by domestic law, where it 
is considered that it would best serve the health needs of the patient and 
where the patient gives informed consent, except that, where the patient 
is unable to give informed consent, the procedure shall be authorised only 
after independent review. 
14. Psychosurgery and other intrusive and irreversible treatments for mental 
illness shall never be carried out on a patient who is an involuntary 
patient in a mental health facility and, to the extent that domestic law 
permits them to be carried out, they may be carried out on any other 
patient only where the patient has given informed consent and an 
independent external body has satisfied itself that there is genuine 
informed consent and that the treatment best serves the health needs of 
the patient. 

Page 996 Mental Illness Inquiry 

15. Clinical trials and experimental treatment shall never be carried out on 
any patient without informed consent, except that a patient who is unable 
to give informed consent may be admitted to a clinical trial or given 
experimental treatment but only with the approval of a competent, 
independent review body specifically constituted for this purpose. 
16. In the cases specified in paragraphs 6, 7, 8, 13, 14 and 15, the patient or 
his or her personal representative, or any interested person, shall have the 
right to appeal to a judicial or other independent authority concerning any 
treatment given to him or her. 

Principle 12 
NOTICE OF RIGHTS 

1. A patient in a mental health facility shall be informed as soon as possible 
after admission, in a form and a language which the patient understands, 
of all his or her rights in accordance with these Principles and under 
domestic law, which information shall include an explanation of those 
rights and how to exercise them. 
2. If and for so long as a patient is unable to understand such information, 
the rights of the patient shall be communicated to the personal representative, 
if any and if appropriate, and to the person or persons best able to 
represent the patient's interests and willing to do so. 
3. A patient who has the necessary capacity has the right to nominate a 
person who should be informed on his or her behalf as well as a person 
to represent his or her interests to the authorities of the facility. 

Principle 13 
RIGHTS AND CONDITIONS IN MENTAL HEALTH FACILITIES 

1. Every patient in a mental health facility shall, in particular, have the right 
to full respect for his or her: 
(a) Recognition everywhere as a person before the law; 
(b) Privacy; 

Human Rights and Equal Opportunity Commission Page 997 

(c) Freedom of communication which includes freedom to communicate 
with other persons in the facility; freedom to send and receive 
uncensored private communications; freedom to receive, in private, 
visits from a counsel or personal representative and, at all reasonable 
times, from other visitors; and freedom of access to postal and 
telephone services and to newspapers, radio and television; 
(d) Freedom of religion or belief. 
2. The environment and living conditions in mental health facilities shall be 
as close as possible to those of the normal life of persons of similar age 
and in particular shall include: 
(a) Facilities for recreational and leisure activities; 
(b) Facilities for education; 
(c) Facilities to purchase or receive items for daily living, recreation 
and communication; 
(d) Facilities, and encouragement to use such facilities, for a patient's 
engagement in active occupation suited to his or her social and 
cultural background, and for appropriate vocational rehabilitation 
measures to promote reintegration in the community. These 
measures should include vocational guidance, vocational training 
and placement services to enable patients to secure or retain 
employment in the community. 
3. In no circumstances shall a patient be subject to forced labour. Within the 
limits compatible with the needs of the patient and with the requirements 
of institutional administration, a patient shall be able to choose the type 
of work he or she wishes to perform. 
4. The labour of a patient in a mental health facility shall not be exploited. 
Every such patient shall have the right to receive the same remuneration 
for any work which he or she does as would, according to domestic law 
or custom, be paid for such work to a non-patient. Every such patient 
shall in any event have the right to receive a fair share of any remuneration 
which is paid to the mental health facility for his or her work. 

Page 998 Mental Illness Inquiry 

Principle 14 
RESOURCES FOR MENTAL HEALTH FACILITIES 

1. A mental health facility shall have access to the same level of resources 
as any other health establishment, and in particular: 
(a) Qualified medical and other appropriate professional staff in 
sufficient numbers and with adequate space to provide each patient 
with privacy and a program of appropriate and active therapy; 
(b) Diagnostic and therapeutic equipment for the patient; 
(c) Appropriate professional care; and 
(d) Adequate, regular and comprehensive treatment, including supplies 
of medication. 
2. Every mental health facility shall be inspected by the competent 
authorities with sufficient frequency to ensure that the conditions, 
treatment, and care of patients comply with these Principles. 

Principle 15 
ADMISSION PRINCIPLES 

1. Where a person needs treatment in a mental health facility, every effort 
shall be made to avoid involuntary admission. 
2. Access to a mental health facility shall be administered in the same way 
as access to any other facility for any other illness. 
3. Every patient not admitted involuntarily shall have the right to leave the 
mental health facility at any time unless the criteria for his or her 
retention as an involuntary patient, as set forth in Principle 16, apply, and 
he or she shall be informed of that right. 

Human Rights and Equal Opportunity Commission Page 999 

Principle 16 
INVOLUNTARY ADMISSION 

1. A person may (a) be admitted involuntarily to a mental health facility as 
a patient; or (b) having already been admitted voluntarily as a patient, be 
retained as an involuntary patient in the mental health facility, if and only 
if a qualified mental health practitioner authorised by law for that purpose 
determines, in accordance with Principle 4, that that person has a mental 
illness and considers: 
(i) That, because of that mental illness, there is a serious likelihood of 
immediate or imminent harm to that person or to other persons; or 
(ii) That, in the case of a person whose mental illness is severe and 
whose judgement is impaired, failure to admit or retain that person 
is likely to lead to a serious deterioration in his or her condition or 
will prevent the giving of appropriate treatment which can only be 
given by admission to a mental health facility in accordance with 
the principle of the least restrictive alternative. 
In the case referred to in subparagraph (ii), a second such mental health 
practitioner, independent of the first, should be consulted where possible. 
If such consultation takes place, the involuntary admission or retention 
may not take place unless the second mental health practitioner concurs. 

2. Involuntary admission or retention shall initially be for a short period as 
specified by domestic law for observation and preliminary treatment 
pending review of the admission or retention by the review body. The 
grounds of the admission shall be communicated to the patient without 
delay and the fact of the admission and the grounds for it shall also be 
communicated promptly and in detail to the review body, to the patient's 
personal representative, if any, and, unless the patient objects, to the 
patient's family. 
3. A mental health facility may receive involuntarily admitted patients only 
if the facility has been designated to do so by a competent authority 
prescribed by domestic law. 

Page 1000 Mental Illness Inquiry 

Principle 17 
REVIEW BODY 

1. The review body shall be a judicial or other independent and impartial 
body established by domestic law and functioning in accordance with 
procedures laid down by domestic law. It shall, in formulating its 
decisions, have the assistance of one or more qualified and independent 
mental health practitioners and take their advice into account. 
2. The review body's initial review, as required by Principle 16.2, of a 
decision to admit or retain a person as an involuntary patient shall take 
place as soon as possible after that decision and shall be conducted in 
accordance with simple and expeditious procedures as specified by 
domestic law. 
3. The review body shall periodically review the cases of involuntary 
patients at reasonable intervals as specified by domestic law. 
4. An involuntary patient may apply to the review body for release or 
voluntary status, at reasonable intervals as specified by domestic law. 
5. At each review the review body shall consider whether the criteria for 
involuntary admission set out in Principle 16.1 are still satisfied, and, if 
not, the patient shall be discharged as an involuntary patient. 
6. If at any time the mental health practitioner responsible for the case is 
satisfied that the conditions for the retention of a person as an involuntary 
patient are no longer satisfied, he or she shall order the discharge of that 
person as such a patient. 
7. A patient or his personal representative or any interested person shall 
have the right to appeal to a higher court against a decision that the 
patient be admitted to, or be retained in, a mental health facility. 

Principle 18 
PROCEDURAL SAFEGUARDS 

1. The patient shall be entitled to choose and appoint a counsel to represent 
the patient as such, including representation in any complaint procedure 
or appeal. If the patient does not secure such services, a counsel shall be 

Human Rights and Equal Opportunity Commission Page 1001 

made available without payment by the patient to the extent that the 
patient lacks sufficient means to pay. 

2. The patient shall also be entitled to the assistance, if necessary, of the 
services of an interpreter. Where such services are necessary and the 
patient does not secure them, they shall be made available without 
payment by the patient to the extent that the patient lacks sufficient means 
to pay. 
3. The patient and the patient's counsel may request and produce at any 
hearing an independent mental health report and any other reports and 
oral, written and other evidence that are relevant and admissible. 
4. Copies of the patient's records and any reports and documents to be 
submitted shall be given to the patient and to the patient's counsel except 
in special cases where it is determined that a specific disclosure to the 
patient would cause serious harm to the patient's health or put at risk the 
safety of others. As domestic law may provide, any document not given 
to the patient should, when this can be done in confidence, be given to 
the patient's personal representative and counsel. When any part of a 
document is withheld from a patient, the patient or the patient's counsel, 
if any, shall receive notice of the withholding and the reasons for it and 
it shall be subject to judicial review. 
5. The patient and the patient's personal representative and counsel shall be 
entitled to attend, participate and be heard personally in any hearing. 
6. If the patient or the patient's personal representative or counsel requests 
that a particular person be present at a hearing, that person shall be 
admitted unless it is determined that the person's presence could cause 
serious harm to the patient's health or put at risk the safety of others. 
7. Any decision whether the hearing or any part of it shall be in public or 
in private and may be publicly reported shall give full consideration to the 
patient's own wishes, to the need to respect the privacy of the patient and 
of other persons and to the need to prevent serious harm to the patient's 
health or to avoid putting at risk the safety of others. 
8. The decision arising out of the hearing and the reasons for it shall be 
expressed in writing. Copies shall be given to the patient and his or her 
personal representative and counsel. In deciding whether the decision 
shall be published in whole or in part, full consideration shall be given 
to the patient's own wishes, to the need to respect his or her privacy and 

Page 1002 Mental Illness Inquiry 

that of other persons, to the public interest in the open administration of 

justice and to the need to prevent serious harm to the patient's health or 
to avoid putting at risk the safety of others. 

Principle 19 

ACCESS TO INFORMATION 

1. A patient (which term in this Principle includes a former patient) shall be 
entitled to have access to the information concerning the patient in his or 
her health and personal records maintained by a mental health facility. 
This right may be subject to restrictions in order to prevent serious harm 
to the patient's health and avoid putting at risk the safety of others. As 
domestic law may provide, any such information not given to the patient 
should, when this can be done in confidence, be given to the patient's 
personal representative and counsel. When any of the information is withheld 
from a patient, the patient or the patient's counsel, if any, shall 
receive notice of the withholding and the reasons for it and it shall be 
subject to judicial review. 
2. Any written comments by the patient or the patient's personal representative 
or counsel shall, on request, be inserted in the patient's file. 

Principle 20 

CRIMINAL OFFENDERS 

1. This Principle applies to persons serving sentences of imprisonment for 
criminal offences, or who are otherwise detained in the course of criminal 
proceedings or investigations against them, and who are determined to 
have a mental illness or who it is believed may have such an illness. 
2. All such persons should receive the best available mental health care as 
provided in Principle 1. These Principles shall apply to them to the fullest 
extent possible, with only such limited modifications and exceptions as 
are necessary in the circumstances. No such modifications and exceptions 
shall prejudice the persons' rights under the instruments noted in Principle 
1.5. 

Human Rights and Equal Opportunity Commission Page 1003 

3. Domestic law may authorise a court or other competent authority, acting 
on the basis of competent and independent medical advice, to order that 
such persons be admitted to a mental health facility. 
4. Treatment of persons determined to have a mental illness shall in all 
circumstances be consistent with Principle 11. 

Principle 21 

COMPLAINTS 

Every patient and former patient shall have the right to make a complaint 
through procedures as specified by domestic law. 

Principle 22 

MONITORING AND REMEDIES 

States shall ensure that appropriate mechanisms are in force to promote 
compliance with these Principles, for the inspection of mental health 
facilities, for the submission, investigation and resolution of complaints
 and for the institution of appropriate disciplinary or judicial proceedings 
for professional misconduct or violation of the rights of a patient. 

Principle 23 

IMPLEMENTATION 

1. States should implement these Principles through appropriate legislative, 
judicial, administrative, educational and other measures which they shall 
review periodically. 
2. States shall make these Principles widely known by appropriate and active 
means. 

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Principle 24 

SCOPE OF PRINCIPLES RELATING TO MENTAL HEALTH FACILITIES 

These Principles apply to all persons who are admitted to a mental health 
facility. 

Principle 25 

SAVING OF EXISTING RIGHTS 

There shall be no restriction upon or derogation from any existing rights of 
patients, including rights recognised in applicable international or domestic 
law, on the pretext that these Principles do not recognise such rights or that 
they recognise them to a lesser extent. 

Human Rights and Equal Opportunity Commission Page 1005 



APPENDIX 6 

GLOSSARY 

AASW: Australian Association of Social Workers 
ABS: Australian Bureau of Statistics 
ACHS: Australian Council on Healthcare Standards 
ACOSS: Australian Council of Social Service 
ADARDS: Alzheimer's Disease and Related Disorders Society 
ADEC: Australian Drug Evaluation Committee. 
AGPS: Australian Government Publishing Service. 
AHMAC: Australian Health Ministers' Advisory Council 
AIDS: Acquired Immune-Deficiency Syndrome 
AIMHS: Area Integrated Mental Health Service 
AMA: Australian Medical Association 
AMI: Alliance for the Mentally 111, Australia 
ANAMH: Australian National Association for Mental Health 
ANF: Australian Nursing Federation 
APS: Australian Psychological Society 
ARAFMI: Association for the Relatives and Friends of the Mentally 111 
ARAFEMI: Association for the Relatives and Friends of the Emotionally and Mentally Ill 
ATSI: Aboriginal and Torres Strait Islander 
CAAC: Central Australian Aboriginal Congress 
CAAS: Central Australian Advocacy Service 
CADE: Residential facility especially designed for the care of confused
 and disturbed elderly 
people in NSW. 
CAMHS: Child and Adolescent Mental Health Service 
CAT: Care and Assessment Team. 

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CATT: Care, Assessment and Treatment Team. 
CASS: Community Accommodation Support Service (SA) 
CCO: Community Counselling Order 
CES: Commonwealth Employment Service 
CETAP: Commonwealth Employment, Training and Placement 
CHASP: Community Health Accreditation Standards Project 
CMHC: Community Mental Health Centre 
CMHS: Community Mental Health Service 
CRISP: Client Registration/Individual Service Plan 
CRS: Commonwealth Rehabilitation Service 
CTO: Community Treatment Order 
DEET: Department of Employment, Education and Training (Commonwealth) 
DNCB: Domiciliary Nursing Care Benefit. 
DISCA: Disability Services of Central Australia 
DSM: Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R
 edition revised) 
DSS: Department of Social Security (Commonwealth) 
ECT: Electro Convulsive Therapy 
GAT: Geriatric Assessment Team. 
GP: General Practitioner 
HACC: Home and Community Care Program (Commonwealth) 
HREOC: Human Rights and Equal Opportunity Commission 
ICCPR: International Covenant on Civil and Political Rights. 
ICD: International Classification of Diseases 
MIND: Mentally 111 Need Defending (WA) 
MINDS: Mental Illness and Nervous Disorders Society (NSW) 
NACON: National Anglican Caring Associations Network 

Human Rights and Equal Opportunity Commission Page 1007 


NAPCAN: National Association for the Prevention of Child Abuse and Neglect 
NGO: Non-Government Organisation 
NH&MRC: National Health and Medical Research Council 
PaNDa: Post and Ante-Natal Depression Association 
PBS: Pharmaceutical Benefits Scheme 
PECU: Psychiatric Emergency Care Unit (WA). 
PET: Psychiatric Emergency Team (WA). 
PMS: Prison Medical Service 
PND: Post-Natal Depression 
PRA: Psychiatric Rehabilitation Association 
RANZCP: Royal Australian and New Zealand College of Psychiatrists 
RCI: Resident Classification Index 
SAAP: Supported Accommodation Assistance Program 
SANS: Supported Accommodation Network St Kilda (Vic). 
SAYRAC: South Australian Youth Remand and Assessment Centre 
SEP: Supported Employment Program 
SHIPS: Satellite Housing Integrated Programmed Support 
STARTTS: Service for the Treatment and Rehabilitation of Torture 
and Trauma Survivors (NSW). 
TAFE: Technical and Further Education (Colleges) 
VMIAC Victorian Mental Illness Awareness Council 
VICSERV Victorian Community-Managed Services 
VMO: Visiting Medical Officer 
WHO: World Health Organisation 

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