PART FIVE: ANALYSIS OF ALL SUBMISSIONS AGAINST THE NATIONAL STANDARDS FOR MENTAL HEALTH SERVICES

• 5.1 Standard 1 Rights
• 5.2 Standard 2 Safety
• 5.3 Standard 3 Consumer and carer participation
• 5.4 Standard 4 Promoting community acceptance
• 5.5 Standard 5 Privacy and confidentiality
• 5.6 Standard 6 Prevention and mental health promotion
• 5.7 Standard 7 Cultural awareness
• 5.8 Standard 8 Integration
  • 5.8.1 Standard 8.1: Service Integration
  • 5.8.2 Standard 8.2: Integration with the Health System
  • 5.8.3 Standard 8.3: Integration with Other Sectors
• 5.9 Standard 9 Service development
• 5.10 Standard 10 Documentation
• 5.11 Standard 11 Delivery of care
  • 5.11.1 Standard 11.1: Access
  • 5.11.2 Standard 11.2: Entry
  • 5.11.3 Standard 11.3: Assessment and Review
  • 5.11.4 Standard 11.4: Treatment and Support
    • 5.11.4.A Standard 11.4.A: Community Living
    • 5.11.4.B Standard 11.4.B: Supported Accommodation
    • 5.11.4.C Standard 11.4.C: Medication and Other Technologies
    • 5.11.4.D Standard 11.4.D: Therapies
    • 5.11.4.E Standard 11.4.E: Inpatient Care
  • 5.11.5 Standard 11.5: Planning for Exit
  • 5.11.6 Standard 11.6: Exit and Re-entry

It was agreed by the MHCA, BMRI and HREOC, that the most useful framework for organising the vast amount of written and verbal data collected through the consultation process, was the National Standards for Mental Health Services (the Standards; see Appendix 8.7) .

The information in this Part 5, and in Part 6, comes from the submissions and public consultations. The information represents a persuasive cumulation of personal experiences but it is not intended to suggest definitive proof or disproof of the implementation of the Standards. The data is analysed according to State and Territory (Parts 6.1-6.8), and then nationally (Part 6.9) for submissions received from national organisations.

In this section (Part 5), we summarise those common themes and provide a small sample of quotes that highlight personal experiences relevant to each Standard. The volume and consistency of the information gathered through this process demonstrates the gaps and the difficulties governments have had across Australia in meeting these Standards.

5.1 STANDARD 1: RIGHTS

The rights of people affected by mental disorders and/or mental health problems are upheld by the Mental Health Service (MHS).

Standard 1 is designed to generally promote and protect the rights of people with mental illness. The Standard is broken down into specific components which set out the criteria for meeting this principle in more detail (see Appendix 8.7).

There was universal concern about the implementation of this Standard across Australia . The concerns (see list below) indicate the continuing vulnerability of people with mental illness, continued exposure to abuse and a lack of access to complaints procedures to identify systemic failures and provide personal redress.

Carers and service providers noted flaws with complaints procedures that resulted in consumers and carers being afraid to lodge complaints. They described fears of retribution and withdrawal of services. Carers who had lodged complaints also felt that they were being 'fobbed off'.

There were also reports that mental health consumers were not being treated with dignity or respect. Experiences ranged from humiliating and degrading treatment in hospital settings to forced interactions with the police. Consumers and carers said that they were not being provided with information about their illness and treatment choices. They also complained that they were frequently denied the right to have others, such as carers and advocates, involved in their care.

Consumers from a Non-English Speaking Background (NESB) reported a denial of access to interpreters by services, which led to difficulties in accessing appropriate treatment and support services.

Another key area of concern was the protection of the rights of one of the most vulnerable groups of consumers - people with mental illness in the criminal justice system. This is a critical issue, given the rising rate of incarceration of people with mental illness (often due to the inability of consumers to access treatment and support services when needed).

In summary, the key issues relating to this Standard, across Australia , include:

• Consumers and their carers are not being provided with information about their rights (Standards 1.2, 1.3, 1.4)
• Consumers and their carers are not being provided with information about available mental health services, mental illness and available treatment and support services (Standard 1.8)
• Consumers from a NESB and their carers are not being provided with accessible information about available mental health services, mental illness and available treatment and support services and how to access them (Standards 1.7 and 1.8)
• Consumers are not being treated with dignity and respect (Standards 1.1 and 1.4)
• Lack of access to interpreters (Standard 1.7)
• Lack of access to advocates (Standard 1.6)
• Problems with complaints procedures (Standard 1.10)
• General failure to protect consumers rights (Standard 1.1)
• Denial of a consumer's right to have others involved in their care (Standards 1.5 and 1.6)
• Staff and services are not complying with relevant legislation, regulations and instruments protecting the rights of people with mental illness (Standard 1.1)
• Concern about the rights of people with mental illness in the criminal justice system (Standards 1.1 and 1.4)
• Concern about Ministerial discretion and the rights of people with mental illness (Standard 1.1)

The following selected quotes from community forums and submissions describe people's recent experiences of mental health services in the context of Standard 1. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

Consumers and their carers not being provided with information about their rights

Failure to inform consumers of their rights. The recent review of the Mental Health Act 1996 revealed continued resistance amongst mental health workers to the philosophy and practice of informing mental health consumers of their rights, including review of orders, involuntary treatment second opinions, use of advocates. The provision of pamphlets listing consumers' rights is the most routine means of meeting the duty to inform. This is a minimum standard and considerable pressure needs to be applied to encourage verbal communication by staff about rights, at levels appropriate to consumer needs, at various times during hospitalisation or care in the community.

(Health Consumers' Council WA , Western Australia , Submission #29)

[X] was not informed of his rights as a Voluntary Patient and was not made aware that he had been made an 'Involuntary Patient'. This had been done without notification, oral or written. This was witnessed by us prior to [X] being placed in a drug induced sleep. He has not obtained or received copies of associated Forms relevant to this admission .... Management of [X]'s case, have violated his rights as a person with a mental illness.

(Carers, Western Australia , Submission #177)

Consumers not being treated with dignity and respect

A lack of dignity and respect in care received from mental health services are reported generally but in particular, forensic patients, young people and Aboriginal patients are reported to be treated poorly.

(Mental Health Community Coalition Consumer and Carer Caucus, Australian Capital Territory , Submission #342)

Why in 2004 are our loved ones still suffering after policy documents from fancy government watchdogs have been released? Why aren't our loved receiving the same quality of care as people with physical illnesses? Are they not worthy of treatment? Where is the concern? There are huge problems with the system and some of the staff within the system. There is physical and sexual abuse still occurring. Why do we still use seclusion where there are no toilets, no water?

(Carer, New South Wales , Parramatta Forum #1)

I stayed in the Psychiatric Intensive Care Unit at the Royal Derwent Hospital - human rights regarding seclusion. There was no access to a toilet so I had to urinate in the corner of the room.

(Consumer, Tasmania , Hobart Forum #3)

By 15 December 2001, our daughter had developed severe oral thrush, her tongue being swollen preventing her from swallowing and talking without great distress. Unbelievably, her meals still comprised solid food (which she could not eat); this situation led to her subsequent malnutrition and severe dehydration which resulted in her losing 12 kilograms and being transferred to medical ward 2 East on 4 January 2002 for prompt life-saving intravenous and naso-gastric treatment ... my wife saw our daughter drinking the toilet water to help relieve her dry and thickly-coated tongue, mouth and throat.

(Carers, Parents, New South Wales , Submission #106)

We are often required to transport these people but they are not criminals, they are ill.

(Police officer, Western Australia , Bunbury Forum #9)

Concern about protection of the rights of the mentally ill in the criminal justice system

Prison is an expensive housing option for the mentally ill: it is also a grave abuse of their human rights.

(Anonymous, Queensland , Submission #67)

In May 2001, as a consequence of that inadequate treatment, he was charged with malicious damage by arson and in April 2002 was found not guilty by reason of mental illness. From May 2001 until June 2003 our son was incarcerated in appalling conditions at Long Bay Prison Hospital . His behaviour throughout that period was exemplary. During all of that time, he was locked for at least 11 hours a day, and often longer, in solitary confinement in a prison cell and was not allowed to have a TV in his cell. He was frequently hungry, due to the poor quality of the food provided.

(Carers, Parents, New South Wales , Submission #75)

[Prisoners] are in a highly restricted environment, have no choice in provision of service, have far reduced access to their support network, have even greater problems in accessing any complaint or oversight body and in allowing such bodies to examine information that they request to be examined.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

Problems with complaints procedures

95% of the reason why you don't get complaints - because they are exhausted and afraid of victimisation.

(Anonymous, Northern Territory, Darwin Forum #27)

I want to talk about what happens to patients if you complain about staff. If you complain you go from the frying pan to the fire! ...You still need the treatment and the service so you don't complain.

(Consumer, Victoria , Morwell Forum #10)

People are afraid to complain. There's a fear of impact if they complain. Even when the evidence is overwhelming, there is still a real fear. The more serious the complaint, the more "they" will try to discredit the consumer. The culture is such that "they" never want to help the consumer.

(Consumer Advocate, Victoria , VMIAC Forum # 9)

A protocol needs to be developed for the dealing with complaints on a prompt basis whether it be from official agencies such as OCA or others including family, friends and carers. A responsible accountable system for dealing with complaints may well assist morale and confidence in the safe care provided by PSU. (Excerpt from Report of findings by the Chief Coroner)

(Carer, Partner, Australian Capital Territory , Submission #305)

...even numerous complaints to the WA Medical Board have been dismissed with such statements as 'time lessens the memory'........... sure, after they kept fobbing off meetings with them and letting time lapse. I went to every viable person in Perth only to crash into brick wall after brick wall. [Y], Head Psych for the state, told me I was just an emotive mother... too right I am!

(Carer, Mother, Western Australia , Submission #103)

Staff and services not complying with relevant legislation, regulations and instruments protecting the rights of people with mental illness

The hospital has reduced the Ward Clerk hours, which leaves her unable to provide the time needed to do the paperwork to comply with the Mental Health Act. Often when a patient is to have a review by the Mental Health Review Board, there is no paperwork ready, no psychiatrist in attendance and no report by the treating psychiatrist.

(Nurse, Western Australia , Submission #55)

Mental Health Review Board (MHRB) fails to uphold human rights of mental health consumers. The MHRB has consistently failed to work to the reasonable extent of the scope of its powers, by testing the attitudes and practices that lead to detention and forced treatment of consumers. The MHRB is widely regarded by mental health consumers with experience of the system as not being worth the effort of contacting. Reviews are routinely limited to 20 minutes, psychiatrists' reports are taken on face value and rarely challenged, procedural fairness is seen by most consumers and advocates as completely absent.

(Health Consumers' Council WA , Western Australia , Submission #29)

Lack of access to advocates

We have also found problems with the system's recognition of independent advocates, who having been specifically requested to act of behalf of a patient regarding a certain matter, are denied the ability to do so. This even occurs when the request has been in writing - demands are made for the request to be rewritten in a standardised format. This causes frustration in the patient and delay in resolving a problem.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

To offset the abuse of human rights occurring on a daily basis, the need for advocacy services is stronger than ever before, and yet funding for these services has steadily diminished. Without access to independent, fully funded, fully trained advocates, human rights will continue to be breached and the effects will continue to be long lasting and impede the recovery of so many consumers. Independent advocacy can be very effective when used pro-actively in mental health service provision.

(Centre for Psychiatric Nursing Research and Practice, Victoria , Submission #323)

Lack of access to interpreters

The lack of interpreters is a real issue. Many of our people don't have carers, they are socially isolated and they have problems with the language. But they are told by many practitioners that they don't work with interpreters so they can't access adequate care.

(Service Provider, Western Australia , West Perth Forum #36)

Interpreter use of people with limited English. The Health Consumers' Council has assisted a Macedonian mental health consumer who was challenging the actions of mental health services to require him to submit to medication and involuntary hospitalisation. The clinical consultation during which the decision was made to place the consumer on an involuntary order occurred without an interpreter. We include an Advocacy report produced at the time of this consultation that highlights our concerns about the failure of mental health service clinicians to engage interpreters. Specific comment: The engagement of an interpreter should not be optional where action under the Mental Health Act is likely or possible.

(Health Consumers' Council WA , Western Australia , Submission #29)

Concern about Ministerial discretion and the rights of people with mental illness

The Minister is sitting on a request for a consumer to go home even after the Mental Health Tribunal has approved his release.

(Carer, New South Wales , Parramatta Forum #1)

During the period of our son's Forensic Order, we have not been satisfied with the 'due process' of administration of conditions of that order. The requirement that the NSW Minister for Health approve these conditions means that the process is inappropriately politicised. Decisions about transfer and leave for patients, seem to be made to appease community attitudes about mental illness and violence, which are steeped in stigma, rather than in the best interest of the patient.

(Carers, Parents, New South Wales , Submission #75)

5.2 STANDARD 2: SAFETY

The activities and environment of the MHS are safe for consumers, carers, families, staff and the community.

There was serious concern that mental health services are not providing treatment and support to ensure the safety of consumers, their families and the community. The lack of services to assist youth, in particular, was noted. Submissions indicated that many consumers are unable to access emergency services even when at risk of self-harm or harm to others.

Families and carers reported fear for their own safety and the safety of their family member, with no or little response from mental health services. Some consumers shared experiences where they were afraid in hospital treatment settings and provided examples where their safety was not adequately provided for.

Submissions and presentations provided examples of consumers dying while in hospital care, or soon after discharge. Some services responded to safety issues by employing security guards and limiting the freedom of inpatients. However, submissions indicate that this response did not improve safety and security, rather it exacerbated stigma issues and feelings that people with mental illness were criminals or "animals".

Fears for personal safety were also expressed by staff. The expressed a need for additional resources and staff support and training in order for mental health services to respond appropriately and ensure the safety of consumers, carers, staff and the community.

Nationally, the key issues raised regarding this Standard include:

• lack of response to family concerns of danger (Standard 2.3);
• excessive use of physical restraint, sedation and armed escort (Standard 2.3);
• excessive focus on security (Standards 2.1 and 2.3);
• problems with the use of security guards with inpatients (Standard 2.3);
• Consumers are not kept safe or protected from abuse in hospital and treatment settings (Standard 2.2);
• inappropriate staff responses to aggressive and difficult behaviour (Standard 2.4);
• need for staff training to respond appropriately to aggressive and difficult behaviour (Standard 2.4);
• safety concerns for children with mental illness (Standard 2.2);
• lack of services for children and youth with behaviour problems (Standard 2.2);
• lack of procedures in hospitals to ensure safety of consumers, carers and the community upon discharge (Standards 2.1 and 2.3);
• inadequate treatment and support services to ensure the safety of consumers, carers and the community (Standard 2.3);
• lack of support and services in the community to protect consumers from abuse (Standard 2.2);
• lack of trust in MHS to ensure safety for the community (Standard 2.3);
• occupational health and safety issues (Standard 2.3);
• safety concerns of staff (Standards 2.3 and 2.5);
• safety not ensured in supported accommodation environments (Standards 2.2 and 2.3);
• the MHS is not communicating vital information with other accommodation service providers to ensure the safety of staff and other residents (Standard 2.3);
• transport of consumers in a manner which is not 'safe and dignified' (Standard 2.3); and
• safety issues due to lack of resources (Standard 2.3).

The following selected quotes from community forums and submissions describe people's recent experiences of mental health services and their areas of concern under Standard 2. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

Safety of people with mental illness not ensured

The only way the people I have mentioned will receive help is if they harm themselves severely or someone else which is more than likely and why should carers have to wait for such a result.

(Carer, Queensland , Submission #109)

Two consumers died at Xmas one who self harmed and took it too far - we referred him to the service as he was very distressed and out of control he was assessed by a case manager as OK but died within the following week; The second went to the service begging to go into the unit as he knew that when he got this depressed he was at risk - this was our experience in the past and he was hospitalised and kept safe; they refused on this occasion - he took his own life a couple of days later.

(Anonymous, Queensland , Submission #113)

Safety of families and carers not ensured

More than half of the time within 48 hours, to a week, of her release we would be back at the emergency room when the medication had worn off and the delusions had returned full force and often she had lashed out at myself or my grandparents.

(Anonymous, Queensland , Submission #82)

[X] subsequently stayed with us for 10 days even though he was clearly very unwell and should not have been released from hospital. He seemed to be getting worse staying with us and constantly paced through the house day and night. [X] became very aggressive towards his family and had problems with his thought processes. His condition was obviously deteriorating rapidly and we were very worried about safety issues, both his and our own.

(Carers, Parents, New South Wales , Submission #198)

Lack of services for children and youth with behaviour problems

I have staff using the expulsion / suspension guidelines to exclude these kids. I have staff being attacked by kids who are on drugs. Because of a lack of services there's nothing left but to exclude these kids. Actually they really need care.

(Teacher, South Australia , Murray Bridge Forum #17)

Safety not ensured in supported accommodation environments

Hostels like St. Bartholomew's House can no longer afford the risk of injury to staff and/or other residents from people who are not having adequate treatment and support from mental health services.

(St Bartholomew's House Inc, Western Australia , Submission #37)

Safety concerns of staff

As well as the serious implications this crisis has for patients, there are very real and unacceptable consequences for staff. In addition to the obvious risks associated with safety and aggression, there is the deleterious psychological impact on staff constantly frustrated in their attempts to deal humanely with these people in a system that is patently incapable of responding adequately to demand.

(Mental Health Workers Alliance , New South Wales , Submission #325)

Excessive focus on security

Some of these security measures convey to the public that the people behind the wire are animals that need to be constrained.

(Carer, New South Wales , Parramatta Forum #4)

Excessive use of physical restraint, sedation and armed escort

...it goes against the grain to see people being made to stay on a trolley, in a cubicle, usually sedated, occasionally mechanically restrained, just because the mental health system is overloaded and poorly resourced. This situation is chronic and untenable.

(Clinician, Victoria , Submission #201)

Generally if a person's level of distress is of such concern to the clinic staff, themselves, family and / or community, the person will be evacuated, generally by air, to Alice Springs for assessment. The distances involved and the use of planes mean that evacuation to the acute service often requires chemical and / or physical restraint. Clearly there are significant safety issues that are evaluated in each case, however it does mean that Anangu are more likely to be chemically and physically restrained during an acute episode.

(Anonymous, Northern Territory, Submission #271)

Problems with using security guards with inpatients

One of the most disturbing practices for me is the use of security guards from a private security firm to facilitate the care of inpatients, due to lack of proper facilities and staffing levels in Bunbury. The hospital regularly employs guards to "special" patients who are considered at risk of either self-harm or absconding. They often use the guards to boost the staffing levels in the unit to try and make the environment safe. This can often mean an untrained person, usually male, following around a very ill or deeply disturbed person in the medical ward of the hospital as well as the psychiatric unit, or is sitting around in full uniform in the psychiatric unit. This has a couple of very major concerns. Firstly, the patient often self discloses to the security guard their personal history ... Secondly, it also gives the patient, visitors and other patients, the impression that the person with the guard is "trouble", i.e. violent, bad, etc.

(Clinician, Western Australia , Submission #55)

Consumers not kept safe or protected from abuse in hospital and treatment settings

I'm a patient in the hospital at the moment under an involuntary order and it was very difficult for me to get here to this forum today ... It's a place where you can get away from the world but there's not much else. The situation is terrible and I can't even have a shower in private. I'm scared and I have no privacy.

(Consumer, Western Australia , Bunbury Forum #17)

In my last admission (one year ago) to a public hospital I was assaulted and many of my things were stolen and some jewellery was flushed down the toilet. I do not blame the other patient because she was very unwell but I expect to be safe when I get admitted to hospital.

(Consumer, Queensland , Submission #204)

I am writing to you in order to express how appalled I am to hear that, eighteen months after the release of the Bunbury Health Task Force Report major problems with clinical safety at the Bunbury Hospital Psychiatric Inpatient Unit still continue ... I can only hope that now, with the release of yet another report, your Office and that of the State Wide Office of Mental Health will be able to insist upon change - before someone is seriously injured, killed or otherwise jeopardised ... (extract from a letter to the Office of the Chief Psychiatrist)

(Clinician, Western Australia , Submission #24)

Need for staff training to respond appropriately to aggressive and difficult behaviour

As a nurse academic and educator, I am aware that it seems that nurses often adopt or are directed to adopt a zero tolerance to aggression and violence, creating an often adversarial stance with patients and thus increasing the possibility of an aggressive episode... This is avoidable and unacceptable workplace practice. Patients deserve better care, nurses deserve high quality ongoing education and support to provide them with the skills and knowledge to care for people with difficult behaviours.

(Academic, South Australia , Submission #142)

Safety issues due to lack of resources

...the increasing service resource crisis presents significant threats to the rights of mentally ill people. This occurs through compromising safety and increasing the risk of sub-standard treatment, undermining centres of clinical academic excellence, increasingly marginalising those with mental illnesses, and through a tendency when addressing clinical problems to rely increasingly on administrative and legal solutions rather than clinically led solutions.

(Public Sector Psychiatrists, New South Wales , Submission #297)

There is a crisis in attracting all disciplines to work in Mental Health due to lack of support/ training and poor working conditions and a lack of attractive career paths. This impacts on comprehensive care and there are recurrent safety issues due to staff dealing with potentially violent and dangerous situations, sometimes without any back up.

(Anonymous, Tasmania , Submission #254)

5.3 STANDARD 3: CONSUMER AND CARER PARTICIPATION

Consumers and carers are involved in the planning, implementation and evaluation of the MHS.

Across Australia there were concerns about the diminishing level, or complete abandonment, of consultation and engagement with consumers and carers in the planning, implementation and evaluation of service delivery. There were reports that critical service delivery decisions were being made without any consultation with consumers and carers. Nor were there attempts to communicate the ramifications of such decisions to this group.

Where such processes were still operating, they were frequently described as 'tokenistic' and consumers and carers did not feel valued. Continued withdrawal of funding and lack of resources to support consumer and carer participation programs was also reported. Consumers and carers described feelings of weariness and 'consultation fatigue.' They are sick of being ignored and frustrated by the futility of participation and lack of progress.

Concern was also expressed that representation is not inclusive of all consumers and carers; for example, the representation of people with Borderline Personality Disorder was noted as lacking.

Nationally, the key issues relating to this Standard include:

• abandonment of participation by consumers and carers in planning, implementation and evaluation processes by the MHS (Standards 3.1 and 3.2);
• lack of meaningful consultation (Standard 3.1);
• 'tokenistic' approach to consumer and carer participation (Standard 3.1);
• views of consumers and carers are not being heard (Standard 3.1);
• views of youth with mental illness and mental health problems are not being heard (Standards 3.1, 3.2 and 3.6);
• consumers with borderline personality disorder, in particular, are not being heard (Standard 3.6);
• lack of funding and resources to support consumer and carer participation (Standards 3.2, 3.3 and 3.4);
• concerns about lack of progress and 'consultation fatigue' (Standard 3.1); and
• need to address barriers to effective participation by consumers and carers (Standard 3.7).

The following selected quotes from community forums and submissions describe people's recent experiences of mental health services and areas of concern under Standard 3. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

Concerns about lack of progress and 'consultation fatigue'

The other thing the NSW government is good at is holding inquiry after inquiry, establishing one task force or select committee after each other - and all it is, is a big talk fest and we go around the same circle for the next 2-3 years or in Australia's case for the next 10 years.

(Consumer and Consumer Advocate, New South Wales , Submission #8)

My son and I have been involved with the Mental Health Association and been on lots of committees and attended many forums and consultations and where are we?

(Carer, Mother, Northern Territory , Alice Springs Forum #13)

Too many times over the years have many other people and I given information, been part of a consultation group, spoken up when asked to do so. Too many times have we been promised that something would be done? Too many times we have been let down. I am certain that somewhere in archives there is a plethora of information that has been collected and not activated on. I like many of my colleagues in the Mental Health System am sick and tired of being told that we have a voice only to find out that we have been fooled once again.

(Consumer, Victoria , Submission #112)

Lack of meaningful consultation

There is a rhetoric of inclusion of the consumer voice in mental health debates but the consumer-survivor experience of this, virtually unanimously, is that this rhetoric is lip-service not matched by any real commitment and certainly not by any meaningful resources to promote the inclusion of the consumer perspective ...

(Insane Australia , Victoria , Submission #232)

Other Consumers Consultants, an apparently smaller group - who measured their situations in various different ways - said that the local Area Mental health Services where they worked remained apparently "resistant and entrenched" toward consumer perspectives, maintaining attitude barriers and "us and them" thinking, and sometimes taking a "pathologising" view of issues. A more subtle but still difficult situation was where consumers perceived that services seemed to be "saying all the right things" but were short on meaningful action - sometimes opting for quick fixes, tick-the-box checklists and "tokenistic" displays of consumer participation through Public Relations exercises, and ever more pamphlets.

(Consumer Advocate, Victoria , Submission #253)

Views of consumers and carers are not being heard

We're at no risk of being threatened for speaking out because we're not being heard at all!

(Advocate, South Australia , Adelaide Forum #15)

Unless people are heard then the government of the day whether it be State or Federal will do nothing.

(Carer, Wife, Australian Capital Territory , Submission #149)

Abandonment of participation by consumers and carers in planning, implementation and evaluation processes by the MHS

Only recently in July, Carers at a Carer Advocacy & Issues Forum in Bunbury met and expressed their frustration regarding the sudden closure of mental health services in their community. Specific concerns regarding the closure of services include: ...The complete lack of consultation with carers, consumers and health professionals regarding the closure.

(Carers WA, Western Australia , Submission #277)

The Health Consumers' Council operated a Mental Health Consumer Advocacy Program for six years until this was de-funded in late 2003. This program supported consumer participation in service decision-making, trained consumers as public speakers on service standards and provided a Participation Payment scheme to assist consumer participation. The most promising feature of this program was the employment of mental health consumers as advocates for service reform. Consumers worked on a part-time basis in a team supporting a wide network of peers involved in service reform work. The cost to the state of this program was in the order of $130K per year - 4 workers, 200 consumer reps, 100 committees. The loss of this program was catastrophic for the emerging mental health consumer movement. Almost all progress against the National Mental Health Plan in respect to consumer participation in mental health services has stopped in Western Australia .

(Health Consumers' Council, Western Australia , Submission #29)

Lack of funding and resources to support consumer and carer participation

Let's talk about consumers being employed within the mental health system. Yes, I'm a consumer employee and I get paid for 30 hours and work close on 48 hours each week ... What my gripe is that we have such minimal hours, that we simply cannot do half the stuff we're capable of and try to put into effect. More often than not we're not acknowledged as having any expertise, definitely expected (in my situation) to perform as a manger yet not paid accordingly. In other areas we're the most under utilised resource within a mental health service - and forget the voluntary crap - we deserve to be paid for a good day's work like any other person in the community.

(Consumer and Consumer Advocate, New South Wales , Submission #8)

To remove barriers to participation more resources need to be dedicated for consultation, organisational commitment and leadership and consumer participation.

(Anonymous, Tasmania , Submission #290)

Views of youth with mental illness and mental health problems are not being heard

While consumer participation has fixed some of the worst bits of the adult mental health system, it is virtually non-existent in youth and adolescent services.

(Youth Participation Worker, Victoria , Submission #255)

For a number of years, YACSA has recommended that the State Government establish and resource a youth health advisory mechanism to provide advice to the Department of Human Services on policy and strategic issues aimed at maximising health outcomes. With issues of mental health, sexual health, drug and alcohol abuse and access to services (particularly for young people in rural, regional and outer metropolitan South Australia ), there is an urgent need to act on the implementation of an appropriate advisory structure to the Minister for Health. Given the Generational Health Review emphasis on regionalisation and community participation, YACSA recommends that the Department of Human Services establish a number of regional Youth Health Advisory Committees in key, strategic locations as determined through the process of decentralising the existing health system. YACSA envisages that the Committees would comprise relevant departmental officers and non-government stakeholders in the youth, community and mental health sectors, as well as representation from young people / consumers. YACSA further recommends that the structure of the Committees be based on the previously successful Youth Views young consumer participation model, with executive support to be provided by existing staff.

(Youth Affairs Council of South Australia , South Australia , Submission #38)

5.4 STANDARD 4: PROMOTING COMMUNITY ACCEPTANCE

The MHS promotes community acceptance and the reduction of stigma for people affected by mental disorders and / or mental health problems.

The submissions and consultations reveal ongoing concerns about the high level of stigma associated with mental illness in the community, the workplace and in treatment settings. These concerns indicate that stigma reduction activities and campaigns to-date have had little real impact.

Consumers and families report feeling completely isolated, lonely and ashamed. They feel like they have no support from anyone. Of particular note is the documentation relating to children of parents with mental illness.

There were submissions describing discrimination in the workplace and exclusion of people in social and community settings. Some of those experiences included people losing their job after they disclosed their illness and people physically distancing themselves from them in public social places (e.g. in pubs and cafes). Some described negative behaviour and remarks from mental health workers, police and accident and emergency staff.

It was highlighted that a lack of access to treatment and support services often results in deteriorating mental health, and this serves to exacerbate stigma-related issues for the community. Thus there is a vicious cycle that perpetuates myths, stereotypes and unnecessary fear. Many pointed out the role of the media in maintaining these myths and stereotypes, and urged for rapid changes in this area.

Nationally, the key issues relating to this Standard include:

• high levels of stigma still prevalent within the community (Standard 4.1);
• high levels of stigma still being experienced by people with mental illness and their children (Standard 4.1);
• social isolation experienced by consumers and their family (Standard 4.1);
• rejection by the community (Standard 4.1);
• offensive remarks by police and accident and emergency staff (Standard 4.2);
• discrimination in the workplace and the need to educate employers (Standard 4.2);
• lack of community acceptance and support (Standard 4.1);
• need for community education (Standard 4.2);
• non-acceptance by mental health workers (Standard 4.2);
• non-acceptance by family members (Standard 4.2);
• discrimination by real estate agents (Standard 4.2);
• problems with terminology and stigma for people with personality disorders (Standard 4.3);
• the impact of lack of access to services on stigma and stereotypes (Standard 4.3);
• stigma associated with 'therapy' as opposed to treatment by medication (Standard 4.1);
• stigma and stereotypes being perpetuated by the media (Standard 4.2); and
• diminishing use of the radio as a medium to promote community acceptance (Standard 4.1).

The following selected quotes from community forums and submissions describe people's recent experiences of mental health services and areas of concern under Standard 4. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

High levels of stigma still prevalent within the community

I have 2 sons who have schizophrenia. [X] (eldest son) had a bad breakdown so we decided we would move to a small community to give him a better chance at life but the stigma here was very bad - when our sons went to the pub for a drink the locals would move away from them.

(Carer, South Australia , Murray Bridge Forum #10)

Stigma is also high in small communities like Broken Hill as people fear what they can't see. In discussions with legal advisors they have encouraged people not to disclose their illness. In addition, community attitudes are often dismissive of people with a mental illness.

(Consumer, Carer & Family Worker, New South Wales, Broken Hill Forum #23)

Admission to mental health facilities or contact with mental health professionals results in fear of consequences for community and professional standing and this fear has a realistic base.

(Support and Equity Services, Charles Darwin University , Northern Territory , Submission #269)

No one understands what is like to have a mental health problem in your family unless they are in the situation themselves. We live a silent pain. Ashamed. Embarrassed. In fear of our lives. Family destroyed. No one wants to help.

(Carer, Mother, New South Wales , Submission #90)

In every discussion held to date, stigma and discrimination have been raised as issues of concern. Unfortunately, the experience of stigma and discrimination is endemic, ranging from the common media portrayal of people with a psychiatric illness being violent and aggressive to discrimination in employment and even to how people are treated in mainstream medical services.

(Brotherhood of St. Laurence and Catholic Social Services Victoria , Victoria , Submission #324)

Social isolation experienced by people with mental illness and their families

...three members of my family who have been diagnosed with Schizophrenia. This has had a devastating effect on not only the immediate family but also on extended family relationships, namely the isolation we have suffered since the diagnoses were made.

(Carer, Anonymous, Submission #224)

[X] finally lost all hope and on the 29 th of May 1999 he laid himself on a train track ... Because of the myths and stigma associated with mental illness his condition became worse. He had nobody to turn to about his problem, as mental illness is something that is not discussed in our society. I also did not have anyone to turn to. It was like something very shameful had hit our family.

(Carer, Mother, Queensland , Submission #81)

My son had schizophrenia and he's now dead as well - he committed suicide. The community didn't understand and when people found out he had a mental illness they dropped him like a hot potato.

(Carer, Mother, Queensland , Rockhampton Forum #9)

I think for those who are severely ill and are isolated in the community due to their illness they often have no form of support even from family or friends. For people like that they are in the community living like ghosts - they are dying alone.

(Consumer, Victoria , Footscray Forum #11)

My son had so many friends, his photo in the local paper every week, and captain of every team he was in, and as soon as the diagnosis came, he'd say "Any mail, mum?", "Any phone calls?", but there weren't any.

(Carer, Mother, Victoria , Submission #211).

Mental illness is a 'hidden' disability for families who are labelled and marginalised along with their unwell relative. Their predominant theme is loss - of the 'well' relative, a lifestyle, a rightful place in their community and their identity as spouse, parent, child or sibling.

(Carer, Wife & Mother , Queensland , Submission #157)

Lack of community acceptance and support

In Western Australia mental health problems are shrouded in ignorance. Few people ever think about the mental health needs of our communities and even less people think about the needs of mothers with mental illness and their children. The cost to our community is only counted in fiscal terms for the Health Department ...

(Health Consumers' Council WA , Western Australia , Submission #29)

The impact of lack of access to services on stereotypes

When my son and others like him are unwell, their behaviour is their stigmata... this policy requires them to be different enough to draw attention to themselves in a totally negative way... thus under this policy the stigma of mental illness is propagated rather than alleviated. And let us not forget that this behaviour, not chosen behaviour, but behaviour dictated by the illness, is that which can cause them to lose accommodation, employment, friends and perhaps even family, thereby having their lives fall apart time and time again.

(Carer, Mother, Victoria , Submission #178)

Because my kids don't get any support, in fact they get teased about having a father who is mentally ill, they then come home and take it out on me; tell me I'm nuts or I'm a loony.

(Consumer, South Australia , Murray Bridge Forum #1)

Discrimination in the workplace

One client did eventually disclose her medical history three months after she got a job and then promptly lost that job.

(NGO Worker, New South Wales , Broken Hill Forum #21)

I am a nurse but I have been told that I will never get a job in this area because of my previous mental health condition.

(Consumer, Nurse, Western Australia , Bunbury Forum #2)

I also have a lot of contact with people who have had bad workplace and insurance issues. Also people who have been working and then need time off work and try to get income support have great difficulty. I also have many clients who have had depression and have lost their jobs because of their illness.

(Clinician, Queensland , Brisbane Forum #20)

There is discrimination in employment. You become ill, get the treatment on sick leave, get well again and are asked to leave.

(Carer, Mother, Northern Territory , Darwin Forum #5)

I took 3 months off from work on personal leave to recover from suicidal thoughts. When I came back, I had to deal with new management and new thinking. Previously, I had a supportive supervisor. I asked for a transfer to another section. The new management sought a psychiatric assessment of my illness. Their solution to the problem was to pension me off rather than look to work with me around the illness.

(Consumer, Australian Capital Territory , Canberra Forum #19)

A female client hospitalised with major depressive episode and a high suicide risk took sick leave from her job, only to be eventually fired due to her illness. This occurred despite the fact that she was planning on returning to work and was progressing well. She later returned to work with another company (she didn't disclose her history).

(Clinician, Queensland , Submission #105)

I advise clients not to disclose to their employer if they currently have or have had depression or any other mental health condition, as ignorance and stigma remain high in the general community and they are likely to be penalised for their honesty.

(Clinician, Queensland , Submission #105)

Stigma and stereotypes being perpetuated by the media 

I'm from the bush and I have bipolar disorder. I agree with the previous speaker that there are many shocking articles in the media that shape the community's attitudes. Stigma is the biggest thing to fight.

(Anonymous, Queensland , Brisbane Forum #12)

While there has been some improvement in media coverage of mental illness, this is not sufficient to counter systemic stigma. Some newspapers and TV dramas also continue to portray mental illness in an inaccurate, sensationalised and disrespectful way. This can suit political leaders, as it displaces blame for the consequences of poor service delivery onto the mentally ill themselves.

(SANE Australia , National, Submission #302)

Discrimination by real estate agents

Housing is difficult - if you present to a real estate agency and declare that you are on a disability support pension you aren't assisted - you'll be rejected!

(Consumer, Queensland , Brisbane Forum #11)

...an eviction notice as he had not been paying his rent ... I then contacted the rental agent from the Real Estate Agency and arranged to meet with her at my son's unit for an inspection and to arrange removal of his belongings. She arrived, followed by two police officers. There was no damage to the unit. I apologised for what had happened and was strongly rebuked by the agent for not having informed her that my son suffered from schizophrenia and added that she would have to inform all other rental agencies that he was an evictee along with my name as his next of kin. (Obviously this would make acquiring further accommodation for him very difficult).

(Carer, Mother, Victoria , Submission #178)

Problems with terminology and stigma for people with personality disorders

...the term, personality disorder, makes people sick ... personality disorder implies that a person's problems are all that person's fault and responsibility ... some clinicians use the term personality disorder indiscriminately as short hand for everything that presents as difficult to diagnose or socially construed.

(Consumers, Victoria , Submission #194)

Stigma associated with 'therapy' as opposed to treatment by medication

Intensive psychotherapy is extremely hard on everybody. The public image that it is somehow what privileged, overindulged, middle class women do to fill in the time needs challenging. I am very concerned that the efforts that have been made by SANE and other organisations to de-stigmatise mental illness have not even tried to do anything about de-stigmatising therapy in Australia

(Consumer, Victoria , Submission #203)

Non-acceptance by mental health workers

SANE Stigma Survey 2004: ... Analysis of over 300 responses suggests that being treated unfairly and disrespectfully - by health professionals as well as the general community - is a regular occurrence for many Australians whose lives are affected by mental illness.

(SANE Australia , National, Submission #302)

5.5 STANDARD 5: PRIVACY AND CONFIDENTIALITY

The MHS ensures the privacy and confidentiality of consumers and carers.

Concerns were strongly expressed across all States and Territories regarding the misuse and incorrect application of policies and procedures designed to protect the privacy and confidentiality of consumers. The complexity of, and misunderstandings about, privacy laws and policies has hindered communication between consumers, carers and clinicians and has led to obstructions in the provision of treatment and support to consumers.

There many examples where mental health professionals have refused to communicate with carers and family even when consumers have expressed a desire, and provided specific authorisation, for others to be involved in their care.

Some carers report a 'double whammy' wherein the mental health care system expects them to assume and accept the responsibility of care but fails to involve them in the development of treatment plans or provide them with the information necessary to fulfil this role. Similarly, carers reported that clinicians were often not prepared to even 'listen' to their notifications regarding signs of relapse or fears for the personal safety of consumers or themselves under the pretext of 'privacy and confidentiality'.

There was also concern that often clinicians mistakenly assume that consumers lack the capacity to give informed consent and for this reason do not discuss these issues with consumers.

The need for culturally sensitive approaches to dealing with information, for Indigenous cultures in particular, was raised as an area of concern.

The privacy and confidentiality of information relating to consumers who are subject to the criminal justice system was also raised as a critical area of concern.

'Privacy', 'private space', control over that space and adequacy of physical care environments are also covered under this Standard. The diminishing importance of consumers having adequate privacy in residential and inpatient settings (both indoor and outdoor spaces) and control over their personal effects was noted. The generally poor condition of mental health inpatient and residential settings was described as being of a standard that would not be acceptable for those receiving care for physical health problems.

Nationally, the key issues relating to this Standard include:

• concerns about policies and procedures to protect confidentiality (Standards 5.1 and 5.2);
• concerns about privacy and confidentiality policies hindering communication with carers (Standards 5.1 and 5.2);
• staff applying privacy and confidentiality rule without authority, ignoring or not requesting permission from consumers to share information or involve carers (Standards 5.1, 5.2 and 5.4);
• the MHS denying consumers their right to have others involved in their care (Standard 5.3);
• reluctance by services to involve carers, even when permission is given by consumers (Standard 5.3);
• problems with access to databases and confidentiality (Standards 5.1 and 5.4);
• indigenous issues (Standards 5.3 and 5.4);
• prisoners and problems with information sharing between agencies (Standards 5.1 and 5.4);
• information sharing with the police (Standard 5.4);
• privacy laws and assisting youth to access care (Standards 5.1 and 5.3);
• rights of carers (carers not informed of discharge) (Standards 5.1, 5.2, 5.3 and 5.4);
• consequences that may follow for consumers and their relationship with carers or significant others if policies and procedures to protect the confidentiality and privacy of consumers are misunderstood (Standard 5.3);
• lack of privacy and outdoor physical space (Standards 5.5 and 5.7);
• concerns about lack of privacy and control over personal space (Standards 5.7 and 5.8);
• inadequate indoor physical care environment (Standards 5.7 and 5.9); and
• loss of personal effects (Standard 5.8).

The following limited selection of quotes from community consultations and submissions describe people's recent experiences of mental health services and areas of concern under Standard 5. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

Concerns about policies and procedures to protect confidentiality

Family, friends and carers could provide information valuable for such a plan and they need to be involved on discharge of patients to be treated within the community. Information from family, friends and carers is important for treatment planning and risk assessment and for the continuation of treatment upon discharge. The problem of patient resistance to the involvement of family, friends and carers and privacy issues needs to be contended with. Best practice does involve this question. It did not happen here at an appropriate level ... (Excerpt from Report of findings by the Chief Coroner)

(Carer, Partner, Australian Capital Territory , Submission #305)

...the laws are often given as an easy way to avoid talking about issues with people involved with the patient regardless of the appropriateness or otherwise of the request, and c) privacy laws are often attacked because they are inaccurately blamed for lack of social support, and general medical information about psychiatric disability comprehensible to the general public that people close to a patient might need ... Generally, no matter what laws are enacted regarding them, the problems of information / privacy issues will always come down to the attitudes of all parties in the practical application of any such laws. These are complex relationship and social issues that have to be dealt with at the grass roots level and through three way learning between professionals, patients and people connected to patients.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

'What is wrong with the CATT [Crisis Assessment Treatment Team] and the emergency processes? It's getting worse. They tell us they are short staffed. They tell us they can't talk to us that it's a matter of privacy and confidentiality, but surely when our lives and our safety are at risk, they must listen to us'.

(Mental Health Community Coalition Consumer and Carer Caucus, Australian Capital Territory , Submission #342)

Staff applying privacy and confidentiality rule without authority, ignoring or not requesting permission from consumer to share information or involve carers

Family members reported that some clinicians are receptive to speaking with and listening to them but that others are not and will cite 'confidentiality' as a reason for not engaging with family members.

(Mental Health Community Coalition Consumer and Carer Caucus, Australian Capital Territory , Submission #342)

Doctrines of confidentiality and privacy of adult patient information are often interpreted by some professionals and adhered to so strongly within that Carers are intentionally not provided with information about medication, treatment and progress. Also, they are frequently denied linkages with those treating the consumer, even though Carers are expected to support and manage the care of the consumer in the community. The reality is that care provided in the community by family members frequently occurs without recognition from the mental health system, the professionals, or the general health care and primary health care sectors.

(Carers Association of SA, South Australia , Submission #30)

Respondent F. spoke of her husband's in-patient psychiatrist as "abrupt, arrogant ...I was supposed to defer to his 'expert' knowledge". Due to privacy legislation, most respondents felt they had not been given a full description of their relative's diagnosis. Respondent C. stated, "even my family doctor would not discuss my son's condition with me ... how could I continue to care for him if I did not know what to expect?" Confidentiality considerations can be an excuse for lack of family members' inclusion in care planning.

(Carer, Wife & Mother , Queensland , Submission #157)

Concerns about privacy and confidentiality policies hindering communication with carers

The mental health system failed [X] in so many ways. In summary the key failings were: ... the role of family members as carers was ignored: they would not listen to our input and apparently valued privacy requirements above everything else, including [X]'s welfare and even his life.

(Carer, Sister, Australian Capital Territory , Canberra Forum #9)

A common problem for carers is the impact of privacy laws and recognition of their role. Each State and Territory has different legislation governing rights of carers and the release of information to carers so that a three-tier system must be overcome prior to information being shared with the mental health service or recognition of their role being granted. This tiered system is comprised of the relevant State or Territory mental health legislation, State or Territory privacy or health legislation and the Federal privacy laws.

(Carers Australia , National, Submission #276)

We as a family were not allowed to be involved with my son's treatment because of the confidentiality law. The law states, that my 19-year-old son - suffering mental illness and living at home - was deemed an adult so we were excluded from his treatment. This was thrown at me - his mother - in every direction and I tried extremely hard trying to contact my son's Doctor's, Psychiatrist and various organisations, but to no avail. (author's emphasis)

(Carer, Mother, Queensland , Submission #81)

Carers continue to report that they feel there is minimal recognition of them by mental health services and minimal efforts to consider their views and/or involve them. Whilst Carers respect the need for confidentiality the lack of possible involvement of carers is a significant barrier to carers in providing care and support for their family members/friends with mental illness.

(Carers WA, Western Australia , Submission #277)

MHS reluctant to have others involved in the care of patients

I have power of attorney over my wife but when I ask for information about my wife they tell me they can't give it to me - until I slap the POA(Power of Attorney) in their hands.

(Carer, Husband, Victoria, Melbourne Forum #3)

Consequences of exclusion of carers and families

I was married to a paranoid schizophrenic and did not know ... No Dr. would tell me - ethics, the result was, this "man" totally destroyed my life, and there was not a thing I could do about that legally ... I am still trying to "pick myself up off the floor", but sadly never will.

(Carer, Wife, South Australia , Submission #148)

Capacity to provide consent

It should never be assumed that the person is incapable of considering a matter, forming an opinion and giving direction regarding the matter. This includes who is privy to information and who may be involved in admission, treatment, and discharge, in terms of Health and non-Health persons and the interaction of the two. There is generally a presumption that any patient with psychiatric disability lacks capacity. This is untrue.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

Rights of carers

...two issues which can cause enormous problems for carers and which I believe can create the greatest divisions in understanding between mental health professionals and carers. The first is 'confidentiality' ... from personal experience and anecdotally, this has proved on many occasions to have the potential to put either the carer or the person with the illness at risk - even if that risk is simply to their personal health and well being, apart from the distinct possibility of far more serious consequences. It is small wonder that carers can often feel used and abused by the mental health system - it appears that there has been little thought given to the rights of carers, or rather their lack of rights; we are expected to accept responsibility for the continuity of care without even the right to be informed of hospital discharges without the patient's consent, and with currently minimal time spent in hospital, the matter of the person with the illness being able to make such important decisions in regard to their own welfare has proven to be highly questionable.

(Carer, Mother, Victoria , Submission #178)

Family carers indicate they have all responsibility but no rights. They are key players in caring for sick family members. The confidentiality / privacy act is an aberration. Carers observe a loved one's illness daily and can warn when episodes/relapses are imminent. Professionals deny themselves access to the wisdom of carers and hinder early diagnosis and accurate diagnosis.

(ARAFMI Tasmania , Tasmania , Submission #245)

The CONFIDENTIALTY LAW needs to be amended. There is no other illness in society that the medical profession do not involve the families or carers. However once a person has been diagnosed with mental illness the confidentiality law is used and abused to the detriment of the family and carers. An example of this abuse is if a person has been diagnosed with cancer, heart attacks, diabetes etc the whole family is involved however if a person who has been diagnosed with some form of mental illness the confidentiality/privacy act comes into play. SO WITH OR WITHOUT THE CONSENT of the person who has been diagnosed with mental illness we the families and carers who are the community care givers and providers MUST be involved, consulted and our opinions respected in determining the health and happiness of our loved ones. Exactly in the same way other illnesses are treated. (author's emphasis)

(White Wreath Association Inc, Queensland , Submission #81)

Indigenous issues

It is a necessity to recognise formally the Indigenous concepts of family, kinship and community, and to allow communities and individuals within the Indigenous communities to work out appropriate ways of dealing with information that affects the relationships within the Indigenous communities. Indigenous Cultures must be respected and Indigenous people must not be forced or pressured to reveal Cultural information. There are arrangements already existing that are supposed to be respected, such as the AHRC / NSW Health Partnership, to look into these issues and ensure that matters affecting Indigenous people(s) are dealt with at all law, policy and service levels in the appropriate and culturally respectful manner. It cannot be allowed to be done in ignorance of the rights and concerns of Indigenous peoples and without self determination. As these issues are already known to government and departments, a choice to ignore the issue and deny rights amounts to a deliberate decision which we contend must be examined with regard to the International Convention on Genocide. We also argue that these issues be examined in the light of the 2003 WHO guidelines on Mental Health Law and Human Rights regarding the protection of Indigenous ethnic groups and minorities.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

Prisoners and problems with information sharing between agencies

We wish to express here our absolute objection that prisoners, as an entire class of people, have by law no right to privacy due to recently passed laws. This discrimination is offensive in and of itself. It is also highly damaging to prisoners' wellbeing and relationships with medical staff and others. Prisoners' patient records have been given to the media, for example the X-rays of the hand of Ivan Milat. (We note that forensic patients' mental state and therapeutic relationship has also been released and discussed in the media, and that this is a nation-wide problem. Forensicare of Victoria is often considered exemplary in debates around forensic standards, but they are in no way immune from problems and have also revealed such personal information in an inappropriate and political manner.)

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

Problems with access to databases and confidentiality

We also completely object to NGO / Police access to databases and information sharing regarding the mental state and medical records of patients as suggested in submissions and hearings at the NSW Parliamentary Inquiry into Mental Health Services. This is an abuse of patient's private information and must not occur. NGO's and Police can contact Mental Health Teams if really necessary.

(Indigenous Social Justice Association (ISJA) and Justice Action (JA), New South Wales , Submission #349)

Inadequate indoor physical care environment

Many people fear that ultimately Graylands Hospital will be closed down, as was Heathcote Hospital . It should always be born in mind that to replace beds in a facility like Graylands Hospital with its peaceful surrounds with extra beds in a general hospital like Royal Perth or SCGH [Sir Charles Gairdner Hospital] with their locked wards and lack of personal space is absolutely a huge step backward!

(Carers, Parents, Western Australia , Submission #76)

There have been complaints made to St Vincent 's but nothing has been done about it. I think it's there to stay. The nurses lobbied for it and said they had it built to protect their patients and themselves from people coming in off the street. I'm not opposed to secure units at all. That's not what I mean. What I mean is that we need to give more thought about how we build secure units. They shouldn't look like cheap prisons. People, even high security people have a right to privacy and respect.

(Consumer Advocate, New South Wales , Parramatta Forum #3)

The James Fletcher Hospital is also frequently "dirty" ... cleanliness could be upgraded to hospital standard. For example, the carpets are very dirty, which leaves patients with black feet. There was an example of food smeared on a window which was left for more than 3 weeks. A dead cockroach was left lying in a corridor for several days. There are frequently coffee stains left on the garden furniture. Overall, it is a very dirty environment, not what you would expect from a hospital. There is also no air-conditioning or fans and so no fresh air. The fans were removed after a patient attempted to hang themself. A plan for installation of air conditioning was developed 12 months ago, but no action has occurred yet. Furthermore, there is only one meal option available to patients, regardless of the individual's tastes or beliefs. There is often no privacy for patients using the telephone because if there is a staff meeting being held in the room housing the phone it is placed in the hallway ... patients are treated as 2 nd class citizens. They do not receive the same level of care you would receive in other health facilities.

(Anonymous, New South Wales , Submission #156)

5.6 STANDARD 6: PREVENTION AND MENTAL HEALTH PROMOTION

The MHS works with the defined community in prevention, early detection, early intervention and mental health promotion.

A recurrent theme at the community forums and in submissions received from consumers, carers, clinicians, academics, advocates and service providers was the concern about lack of resources and plans to support early intervention and prevention. Participants noted the serious negative consequences this has for consumers, carers and the community.

Submissions and representations described a failure to provide early intervention and implement prevention programs. Consumers, carers and providers also said access to care was practically impossible when people were becoming seriously unwell. Consumers are regularly told they can not access services until their health has deteriorated further. For example, one consumer was told he was 'not psychotic enough'.

For some consumers an inability to access timely services led to deteriorating mental health which, in turn, led to behaviour resulting in entry into the criminal justice system. Others entered a 'revolving door' pattern of admission for acute care due to a lack of rehabilitation programs and ongoing support.

Carers reported that clinicians need to engage with consumers and, with consent, their family members to develop plans to identify early warning signs of relapse. Family members then need to be heard and the information acted upon.

The lack of services for youth, and the implication this has for attempts to avert long-term negative life consequences, was highlighted as a particularly significant deficiency. Similar concerns were expressed about the lack of early intervention and prevention programs to deal concurrently with mental illness and substance abuse problems.

Reports were also received regarding the lack of effective mental health promotion strategies, particularly for children at school, for people who are hearing impaired and for those who come from a Non-English Speaking Background. A better promotion strategy would help consumers, carers and the community at large to identify early warning signs and assist in seeking the appropriate care. On the other hand, service providers noted that it is unfair to promote early intervention and prevention to the community when services do not have sufficient resources to respond to crises.

Nationally, the key issues relating to this Standard include:

• due to lack of access to services, no prevention or early intervention is happening (Standard 6.1);
• no attempts at and lack of focus on early intervention or prevention - reactive, crisis driven approach to service delivery (Standard 6.1 and Standards 6.4 - 6.8);
• lack of services for youth - no early intervention or mental health promotion possible (Standards 6.2 and 6.5);
• early intervention - families need to be heard (Standard 6.1 and 6.7);
• early intervention - involvement and role of GPs (Standard 6.5);
• early intervention - importance of open discussion and acceptance (Standards 6.2 and 6.3);
• more promotional strategies needed (Standards 6.2 and 6.3);
• lack of rehabilitation programs (Standard 6.8);
• social needs are not being met through the use of mainstream agencies (Standard 6.9);
• prevention - substance abuse and mental illness need to be tackled jointly (Standards 6.4, 6.5 and 6.6);
• preventing depression in older men (Standard 6.4);
• need for education campaigns in schools (Standard 6.2);
• lack of support for children of parents with mental illness (Standard 6.4);
• unfair to promote early intervention when services are failing to cope with current demand (Standards 6.1 and 6.10);
• need for more programs to promote mental health and prevent mental disorders in the deaf community (Standards 6.2 and 6.3); and
• need for more programs to promote mental health and early intervention to people from a non-English speaking background (Standard 6.3).

The following selected quotes from community forums and submissions describe people's recent experiences of mental health services and areas of concern under Standard 6. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

Due to lack of access to services, no prevention or early intervention is happening

Consumer relapse knowledge ignored. Consumers who feel themselves to be becoming unwell have little or no access to assistance from their treating team. It is not uncommon to contact a clinic on behalf of a consumer who feels the need for immediate intervention and be told that the referral will be placed on a list to be discussed at an 'intake' meeting at a later date ... It is the experience of mental health consumers with early signs of relapse or episodes of need that the inability of services to respond to their needs pushes them towards crisis, disruption of their life and greater need to call on those same mental health services.

(Health Consumers' Council WA , Western Australia , Submission #29)

No attempts at and lack of focus on early intervention or prevention - reactive, crisis driven approach to service delivery

Despite the seriousness of the disorders, there is no philosophical or legal framework supporting a more assertive or early intervention approach, nor the funding capacity to support such a model. Indeed such an endeavour is still impeded by a residual moral dimension to understanding these disorders. The clinical focus is typically on advanced phases of disorder (even in young people) where treatment can no longer be withheld, yet when it may be much less effective.

(Patrick McGorry, Professor of Psychiatry, Victoria , Submission #180)

Crisis Assessment and Treatment Services are variable in their response. Family carers seeking early intervention can find it difficult to get an assessment from the CAT service until their relative has deteriorated to a point where inpatient admission may be the only solution.

(ARAFEMI Victoria , Victoria , Submission #230)

In Canberra , I tried to get access to mental health care when I was becoming unwell. The doctor estimated that I wasn't psychotic enough. The doctor told me they couldn't help as they didn't have the resources, but if I was becoming more unwell and reached a point where I couldn't leave my apartment then I should "give him a call". If people are that unwell these things are beyond them!

(Consumer, Australian Capital Territory , Canberra Forum #21)

On 4 December 2001, my wife discussed our daughter's condition with her treating psychiatrist, the MHU [Mental Health Unit] Psychiatric Registrar and MHU nursing staff, who agreed that the MHU did not cater for our daughter's then current mental state - she was not psychotic. At the request of my wife, and our daughter's clinical psychologist, our daughter was placed in the MHU lock-up ward for her physical protection. It was not until four weeks later, when our daughter's condition had significantly deteriorated, that she was "specialled". We later discovered by accident that "specialling" is normal procedure for vulnerable patients. It seems reasonable that early "specialling" for our daughter would have significantly reduced the severity, duration and cost of her confinement and prevented her ongoing loss of hair and teeth problems from unnecessary malnutrition.

(Carers, Parents, New South Wales , Submission #106)

I would like to comment on the fact that people with a mental illness are being arrested because often it's the only way they can get any help. They have a right to get care, not be arrested. We've got to get access to early intervention programs but it doesn't happen - now my brother is in the court system, not because he's bad but because he's got a mental illness.

(Carer, Sister, Western Australia , Bunbury Forum #24)

Lack of services for youth - no early intervention or mental health promotion possible  

Youth mental heath services ... At the moment there's no access to services at all - previously there was a 6-months waiting list - so the notion of early intervention or prevention doesn't exist for this community.

(Western Australia , Bunbury Forum #8)

Early intervention - families need to be heard

What is acceptable about a clinician making an assessment in a 15 minute appointment whilst ignoring the information of these same carers who are in the position of being far more sensitive to the signs of deterioration in the person for whom they care?

(Carer, Mother, Victoria , Submission #178)

Early intervention - involvement and role of GPs

At the Forum in the Melbourne Town Hall on Monday, I picked up a card saying "Mental Health-GP Business", and I'd just like to be sure that GPs now can pick up mental illness symptoms in young people. When my son was suddenly diagnosed at 21 with chronic paranoid schizophrenia, which was such a shock, we heard from him later that at 15 he'd been seeing our GP, because he knew there was something wrong. (he always had great insight), the Doctor felt he looked so well and fit, he sent him off.

(Carer, Mother, Victoria , Submission #211)

Prevention - substance abuse and mental illness need to be tackled jointly

Significant substance abuse problems exist in Aboriginal remote communities, resulting in significant mental health problems. .

(Anonymous, Northern Territory Submission #188)

Most participants reported taking drugs at early ages (12-14 years) and experiencing psychotic episodes some years later. Commonly, they did not seek help or recognise that they needed help. They reported having a vague understanding of what schizophrenia is but they failed to associate their own experiences with such a mental illness. In most cases, the first episode of their mental illness was diagnosed when they were brought into hospital by police and assessed and hospitalised in the psychiatric ward.

(NSW Association for Adolescent Health, New South Wales , Submission #98)

Preventing depression in older men

Men need more support - because they don't ask for help. There's nothing in this town for men - no support. My partner phoned his parole officer to ask for help because there was nothing else for him.

(Consumer, New South Wales , Broken Hill Forum #24)

More promotional strategies needed

There is a general lack of awareness and information about mental illness, so that those affected and their friends and family members may not realise that they are becoming unwell.

(Health and Community Services Network, Murray Mallee Strategic Task Force,
South Australia Submission #115)

Need for education campaigns in schools

[Y] added there needs to be more education about mental and physical illness and disabilities in schools. They have sex education and drug awareness and healthy eating education at his school but he hasn't been to a school that talks about mental illness.

(14 year old Consumer and Carer (Son), Young Carers Forum Canberra #2)

Lack of rehabilitation programs

The lack of ongoing rehabilitation programs also means that we see a lot of young people, especially, being discharged after treatment but then without the necessary support, quickly becoming unwell again and the cycle constantly being repeated.

(Carer, Mother, Tasmania Submission #315)

This means that as there is no follow up people return to their previous bad state and so these clients have to repeat the whole the process.

(NGO Worker, New South Wales , Broken Hill Forum #5)

He had support through Eureka . He looked forward to it - he did it for 2 years then they told him he had to stop because there wasn't enough funding and someone else had to have a go. He got very depressed, very ill and became very violent. He broke someone's arm and was arrested and taken to the hospital.

(Carer, Tasmania , Hobart Forum #22)

There's a real lack of services to help people get back into society to rehabilitate.

(Clinician, Queensland , Brisbane Forum #7)

We have a son... with a mild intellectual disability ... 22 years of age and remained in that job for ten years feeling a 'normal' part of the community ... Due to all this floundering over the past two years our son now 34 has regressed to a point where he is now in a community care unit seeming as though he has lost all hope of getting anywhere, his hygiene medication and budgeting skills at an all time low. My husband and I both 70 are no experts in mental health but feel had there been positive intervention in the beginning instead of lying about home he would be less reliant on the medical system now, plus the government spending good money into these job agencies which are totally dysfunctional.

(Carers, Queensland , Submission #150)

The Health System's main approach to people with Mental Illness is to get them medicated and then very little else. There are no serious rehabilitation facilities.

(Carer, Father, Victoria , Submission #231)

5.7 STANDARD 7: CULTURAL AWARENESS

The MHS delivers non-discriminatory treatment and support which are sensitive to the social and cultural values of the consumer and the consumer's family and community.

Concern was expressed regarding the lack of culturally sensitive treatment and support for Indigenous people and people from a Non-English Speaking Background (NESB). For Indigenous people, access to care was reported to be complicated by discriminatory attitudes by some clinicians who often refuse treatment on the basis of prevailing stereotypes (for example belief in intoxication or drug misuse as the only cause of the behaviour). There were also reports by clinicians and carers that some staff impose their own spiritual and cultural beliefs on consumers by ridiculing consumers or passing judgment. Further there seems to be a failure to consider service delivery in the context of global Indigenous disadvantage and community needs

The need for specific training and employment of mental health workers with relevant experience appears to be an essential missing ingredient.

Nationally, the key issues relating to this Standard include:

• lack of culturally appropriate practices for NESB consumers (Standards 7.2 and 7.3);
• lack of culturally appropriate treatment and support services for Indigenous consumers and their families (Standards 7.2 and 7.3);
• lack of treatment and support services for older immigrants and newly arrived young people (Standard 7.1);
• problems with treatment due to cultural barriers and intellectual disability (Standard 7.3);
• social and cultural prejudice by staff towards Indigenous people with mental illness (Standard 7.5);
• need for cultural competency training (Standard 7.5);
• need for training of interpreters on mental health issues (Standard 7.3);
• utilisation of staff and services with expertise to provide services to consumers from a NESB (Standard 7.4);
• staff imposing their own religious and cultural attitudes on consumers (Standard 7.5);
• cultural background not being respected and considered in the delivery of treatment and support (Standards 7.1- 7.4);
• lack of sensitivity to spiritual beliefs (Standard 7.3); and
• the need to understand issues associated with recent immigration (Standards 7.1 - 7.4).

The following selected quotes from community forums and submissions describe people's recent experiences of mental health services and areas of concern under Standard 7. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

Lack of culturally appropriate treatment and support services for Indigenous consumers and their families

My son committed suicide 2 years ago. There are a lot of deaths here amongst Indigenous youth. Before he killed himself my son went to the mental health unit and they told me he was suffering from behaviour problems - the perception was that because he was an Indigenous young man that he was 'sloshed out'. We were told that he wasn't suicidal.

(Carer, Mother, Queensland , Rockhampton Forum #3)

When Indigenous people become unwell they are all put in baskets, they either have a mental illness or a drug and alcohol problem. There's no holistic care. There have been 20 close deaths in my family.

(Anonymous, South Australia , Murray Bridge Forum #15)

If the current mental health system works at its optimum level, there are still critical and serious service provision gaps. Anangu do not have access to a spectrum of interventions that are culturally appropriate and responsive to individual and / or community need. There is no access to counselling, grief and trauma support, early intervention programmes or ongoing rehabilitation programmes if someone has been diagnosed with an ongoing disability.

(Anonymous, Northern Territory, Submission #271) 

Underlying this submission are several assumptions of knowledge:

• Indigenous Australians have significantly worse health outcomes than the general population, including higher rates of mental health concerns

• The mental health concerns of indigenous Australians need to be viewed in the context of global disadvantage including poverty, reduced life expectancy and chronic ill health, as well as issues of cultural dislocation, trauma and grief.

• Anangu view mental health issues as part of a general concept that includes the health of the individual, family, community and land in a cyclic view of past, present and future.

(Anonymous, Northern Territory, Submission #271)

By far and away the most prominent mental health concern facing the communities to which I travel [remote communities in Central and North West Queensland ] are those of accumulated grief and loss and the intergenerational consequences of such losses. The history of colonization and cultural oppression represents over and over as symptoms of trauma, depression, drug and alcohol abuse, relationship breakdown and self harm. Tragically, the current, mental health system seems ill-equipped to deal, in culturally appropriate ways, with the complexities of Indigenous health.

(Clinician, Queensland , Submission #285)

Lack of culturally appropriate practices for NESB consumers

People who do not speak English as their first language have very limited access and their linguistic and cultural needs are not met.

(NESB Consumer Advocate, New South Wales , Parramatta Forum #8)

Anecdotal evidence further suggests a disregard within the system for the cultural and religious beliefs of people in patient psychiatric settings. Such anecdotes include no attempts to meet the dietary requirements of religious and cultural groups, and a complete lack of sensitivity to exposure of parts of the body and / or nakedness.

(Australian Nursing Federation (Vic Branch), Victoria, Submission #322)

Need for cultural competency training

Cultural competence doesn't exist at the level it's needed. No cultural competence is taught. Unless we make it as a core competency, it won't happen.

(Anonymous, New South Wales, NESB Parramatta Forum #14)

Staff imposing their own religious and cultural attitudes on consumers

[I] attended the hospital with a friend who had attempted suicide. This was after hours. When I took her to the A and E she was initially checked over for any physical effects of the overdose she had taken. She also reported that she had been abused as a child. The consulting doctor then talked to her at length about religion indicating to her that people who commit suicide "go to hell". This greatly upset my friend who was already very upset. She said later it made her feel guilty about what she had done ...An understanding and non-judgmental attitude would also have helped.

(Clinician, Western Australia, Submission #333)

Lack of sensitivity to spiritual beliefs of consumers

Also it's insulting to not believe the spirituality of the consumer. My daughter has been ridiculed about her belief in God and how prayer helps her. This occurred in our Psychiatric Hospital here in Bendigo .

(Carer, Victoria, Submission #199)

Need for training of interpreters on mental health issues

Language and cultural barriers are often not overcome because skilled and experienced interpreters are not available. Also interpreters will often have to play a role as a bi-cultural worker, to bridge the gap in cultural understanding.

(Melaleuca Refugee Centre, Northern Territory, Submission #191)

5.8 STANDARD 8: INTEGRATION

5.8.1 STANDARD 8.1: SERVICE INTEGRATION

The MHS is integrated and coordinated to provide a balanced mix of services which ensure continuity of care for the consumer.

Concerns were expressed across Australia from consumers, carers and clinicians alike that mental health services are not integrated and coordinated due to a lack of resources, staff and planning. There is a perception that the situation is progressively becoming worse.

Reports also suggest that the mental health system is unable to provide a mix of services to respond to consumer needs, even during a crisis. This results in a reliance on the police for a response. Even with police intervention and assistance in taking people to appropriate care facilities, consumers were often sent home again without any arrangements for treatment or follow-up.

Treatment and support services for children and youth with mental illness across Australia seem to be almost non-existent. Submissions suggest that there are either no services at all or extremely long waitlists (for example, a nine to ten month waiting list for children with mental illness to get into care). Thus the need for integrated and coordinated care for this group is particularly pressing.

Many General Practitioners spoke of their willingness to be involved in the provision of mental health treatment and support, but noted difficulties in doing this without the necessary professional support.

High staff turnover and frequent staff rotations between programs and sites was also mentioned as a difficulty in providing continuous and coordinated care. Consumers report that they are tired of repeating their story and frustrated at being passed from one doctor to another. Fragmented service delivery and breakdown of links with NGO service providers seems to be another consequence of the scarcity of resources.

Nationally, the key issues relating to this Standard include:

• MHS not integrated to provide the mix of services required to respond to consumer needs (Standard 8.1.1);
• MHS not providing continuity of care for consumers (Standard 8.1.5);
• more staff and resources are required for integrated service to respond effectively to crises (Standard 8.1.1);
• chronic under-resourcing of MHS resulting in inability to deliver integrated and coordinated care (Standards 8.1.1 and Standard 8.1.2);
• difficulties in organising integrated and coordinated care with components of the MHS (Standards 8.1.2 and 8.1.3);
• lack of staff and resources to provide integrated care to rural and remote communities (Standard 8.1.1);
• shortage of mental health staff to provide integrated care across settings and programs (Standards 8.1.2 and 8.1.3);
• difficulties accessing case managers (Standard 8.1.1);
• inability to provide coordinated continuous care due to high staff turnover and staff rotations, especially in rural and regional areas (Standard 8.1.4);
• no continuity of care leads to lack of communication (Standards 8.1.3 and 8.1.6);
• lack of cooperation within MHS leads to poor attitudes towards rural and regional patients and providers (Standards 8.1.1 and 8.1.6);
• lack of mental health services for children and youth (Standard 8.1.5);
• problems with continuity between adolescent and adult mental health services (Standard 8.1.5);
• problems with link between General Practitioners and mental health services (Standard 8.1.6);
• problems with integration with NGO services (Standard 8.1.5);
• general Practitioners lack the skills to treat people with mental illness or mental health problems. (Standard 8.1.5);
• inability of MHS to deliver coordinated and integrated services to consumers from a non-English speaking background (Standard 8.1.1);
• inability of mental health teams to provide services resulting in reliance on police force (Standard 8.1.1); and
• problems with Schedule II procedures and integrated and coordinated care (Standard 8.1.6).

The following limited selection of quotes from community forums and submissions describe people's recent experiences of mental health services and areas of concern under Standard 8.1. More detailed descriptions of experiences relevant to this Standard can be found in Part 6:

MHS not integrated to provide the mix of services required to respond to consumer needs

[X] ... is escorted to the emergency department of the local hospital ... [Y] ... assessed [X] to be at high risk of suicide. No admission and no follow-up is arranged. Additionally, no contact was made with the referring agency and according to [X], no request of discussion with the referring agency was sought by mental health services.

(Support and Equity Services, Charles Darwin University , Northern Territory , Submission #269)

Lack of communication and co-operative case management between inpatient and outpatient hospital staff can cause serious errors in treatment. At one time [X] was in hospital for 4-5 days before the inpatient staff knew what the treatment orders were!

(Carer, Mother, Victoria Submission #320)

Chronic under-resourcing of MHS resulting in inability to deliver integrated and coordinated care

This support is not being provided and has been progressively withdrawn over the last several years. The patients are constantly disappointed by the diminished level and duration of service as provided by the state funded public psychiatric system.

(Clinician, Victoria , Submission #123)

Some of the issues that matter are poor accessibility, lack of access to private practitioners, lack of bulk-billing GPs and lack of accessibility to counselling services particularly for people with high prevalence disorders.

(NGO worker, Victoria, Morwell Forum #7)

Lack of staff and resources to provide integrated care to rural and remote communities

I have been advocating for improved psychiatric services in this region for 8 years now. Over 1/3 of our GPs have undertaken additional training. But there's no psychiatrists East of Dandenong! As GPs we have little to no support from the specialist sector.

(Clinician, Victoria , Morwell Forum #8)

More staff and resources are required for integrated service to respond effectively to crises

4 weeks ago a young man came to see me. He was suicidal, he had several crises in his life he was trying to deal with and he had been self-medicating. I see many people like him - they are not bad people but people who need assistance from society. I managed to get him assessed by a crisis assessment service - that in itself was a really big win! But the crisis service was going to send him home with some phone numbers. Fortunately I had organised to see him and got irate and asked them how they would feel if this young man was dead in the morning.

(Clinician, Queensland , Brisbane Forum #7)

I have a friend who had a mental breakdown ... I rang the mental health team and they couldn't see her for 5 days no appointment for 3 to 4 weeks. The GP tried to cope. Good clinicians took details but 3-4 weeks later was asked the same questions again. There is a lack of staff - the team in community and lack of coordinated services.

(Anonymous, Western Australia , Geraldton Forum #65)

The community staff are stretched to the maximum and their resort is to tell people to go to their GP or access an emergency service (was one very recent answering machine message I happen to hear when I was trying to contact a community health worker. Mind you, no information about how to contact the emergency service was part of the message.)

(Consumer and Consumer Advocate, New South Wales , Submission #8)

MATT (mobile assertive treatment team) - work with severely sick psychotic people to keep them out of hospital - only one team with 7 staff who see 70 clients for the Central Sydney area which has 5000 consumers, 500 of whom would benefit from seeing the MATT team, which provides intensive case management, support, counselling and supervision

(Consumer and Consumer Advocate, New South Wales , Submission #169 )

Shortage of mental health staff to provide integrated care across settings and programs

[[X] went] to a psychologist just 2 months before he died - who referred [X] to a psychiatrist - but unfortunately the psychiatrist was away on holidays - so he couldn't get an appointment - in the detailed referral it was obvious to blind Harry that [X] was screaming out for help he had in a one hour session with the psychologist relayed every vital piece of information in regard to his condition. [X] should never have been allowed to leave that psychologist's office - in the referral it said he had a (suicide) plan - it wasn't the first time etc etc.

(Carer, Mother, New South Wales , Submission #122)

Lack of mental health services for children and youth

I've been on a few committees and it's not the service providers who are the problems; they are on our side. It's the politicians and our government that are negligent ... There's a 9-10 month waiting list for mentally ill children to get into care.

(Consumer, Western Australia , West Perth Forum #41)

Problems with continuity between adolescent and adult mental health services

Young people 16-17 come and see us but we do some transitioning to the adult mental health service also. There