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MENTAL HEALTH AND A MATURE SOCIETY - WHO CARES?

Mental illness and psychiatric disability in Australia have been the subject of major review.[i] Positive mental health, in the sense of the capacity to lead satisfyingly balanced, productive and resilient lives, is poorly studied and attracts little policy comment.[ii]

This essay shows that we are facing a critical time in the 'mental health status' of our nation.[iii] While mental illness and psychiatric disability are the focus of a National Mental Health Strategy adopted by Commonwealth and State Governments,[iv] the promotion of mental health in a positive, whole of life sense remains neglected.

The holistic concept of mental health about which we write is neatly captured in the notion of 'the caring society'. Viewed as the summation of all of the best qualities of mutuality that characterise true civilisations, we argue in this essay that by forgoing any notion of being caring, Australia risks forfeiting the gains that were made over the first three quarters of this century.

Where Tom Kewley [v] could proudly document major achievements of successive Australian Governments in social services and income security from 1900 to 1978 any update of his account would tell a sorry story of regression. The present downturn in social provision is justified by the misnomer of "mutual obligation". It thus apes similar social welfare regression in all the English speaking countries of the OECD, where policies such as "Social Responsibility" and "work for the dole" (New Zealand), workfare (the United States) and Blair's "Third way" which reinterprets Thatcherism in the United Kingdom.[vi]

Notwithstanding the progress in medicine, psychology and alternative therapies, by the sort of measures that we propose as reasonable for an advanced nation we do not have a 'mentally healthy' society.

This essay argues that for as long as 'mental health' is merely a construct of the health system, with funding skewed towards clinical crisis intervention, progress will be measured only in terms of the control or management of mental illness. This is a far cry from the goal of holistic (wholeness-oriented) health policies and programs that are a mark of the mature society.[vii] We put forward a series of proposals for a redirection of effort, hoping that these will be vigorously analysed and debated.

Australians deserve a collaborative, coherent, comprehensive and caring mental health system that responds both to individual and cultural identity. For it to be collaborative it has to utilise the efforts of people experiencing mental health difficulties, their families, friends, neighbours and community agencies working with and supported by programs provided by the three levels of government in Australia. For it to be regarded as coherent it has to be unified by a genuine intention to meet minimum standards of provision for all Australians, recognising specific requirements of language, cultural and religious affiliation and specific communication requirements. We point specifically to the situations of relative neglect within the Indigenous and Deaf communities in Australia, highlighted in the Report of the HREOC National Mental Illness Inquiry.[viii]

The coherence we envisage is one that allows diversity of provision to replace the existing system of farraginous forms of negligence and avoidance. The program needs to be comprehensively available. Pockets of neglect should no longer be tolerated, the excuse of the tyranny of distance is just that - an excuse: it simply amounts to a failure to train, invigorate, support and sustainably utilise the community capacity which is available in rural and remote areas.

In urging comprehensive and coherent service systems, we also draw attention to the dangers of systems that are so generalised as to be superficial, bland, and lacking in focus. Some of the aims and principles of 'broadbanded' integrated service provision such as proposed for the Victorian Department of Human Services 'Primary Health and Community Support' demonstration projects are laudable. There are distinct dangers, however, in the effort to be 'all things to all people' when resources will be spread across a massive array of service requirements.[ix]

The approach to service provision we propose was in fact exemplified in the best of the short lived Australian Assistance Plan community development thinking of the mid 1970s. There the emphasis was on pursuing community objectives, valuing the contribution of the community members who participated, and attempting to convey to all people that they were respected in and of themselves, no matter what their status or views.[x]

Modern management practice makes much of 'the balanced scorecard' approach to performance appraisal and evaluation. In mental health terms, Australia has a distinctly unbalanced scorecard.

Even cursory examination of social statistics highlights the following causes for concern:

1. Updated analysis of the 'poverty line' data instituted by Ronald Henderson in his famous reports of 1975 [xi] clearly shows a continuing gap between rich (especially the super-rich) people and those living in poverty (as defined).[xii]
2. Unemployment remains at a high level (relative to national employment capacity and federal Government policy objectives), with little improvement in youth employment. In the first term of the Howard Government unemployment only once dropped below 8% in seasonally adjusted terms and is currently hovering between 7.4% and 8%. Youth unemployment is in the high 20%, indigenous unemployment depending how it is measured is between the high 30% and 80% (much indigenous employment is disguised unemployment because of the Community Development Employment Program [CEDP] which is a work for dole scheme on indigenous communities.[xiii]
3. Ongoing reduction in the employment opportunities for unqualified young people, continued 'downsizing' of major corporations, the 'casualisation' of the workforce, and concentration of employment in conurbations are all putting more pressure on families, especially those with young school-leavers.
4. Reported suicides and attempted suicide are increasing among young people and older Australians (especially men), at rates not explainable by population growth.[xiv]
5. Organisations working with people who experience psychiatric disabilities or mental illness document increasing demands on their services at a time of decreased funding of both community based services and clinical treatment facilities.[xv]
6. The Colleges of General Practitioners and of Psychiatry both report increasing numbers of people, especially middle and upper aged people with symptoms of severe depression who are not receiving appropriate treatment and support.
7. The Australian Institute of Health and Welfare statistics show growing reliance of Australians on both prescribed and illicit drugs. Commentators posit that drugs are increasingly used as 'props' against feelings of anxiety and depression.[xvi]

These are the quantitative measures of mental ill health. There are also many qualitative indicators supporting the thesis that all is far from well on the broad mental health front.

The initiatives taken recently to stem the tide of retreat from private health insurance, particularly the provision of a $1.8 billion subsidy to the predominantly wealthy section of society, will not assist the public mental health system. Indeed, it seems likely that Australia's health system overall will continue to stagger and stumble, partly under the weight of the expectations created for it. Many of the key social indicators point to growing disparities between those who have much and those who have little. Long term unemployment, especially among young people, remains a major social problem. There is no visible progress towards resolution of disparities between services for white Australians and those available to Aborigines.[xvii]

Consider also the following points of concern:

• Charities report greater numbers of people in part time employment coming for basic support - food, clothing and household furniture. This often includes two parents with part-time jobs totalling less than 20 hours per week between them.[xviii]
• Charities also say that it is increasingly difficult to raise money - or sympathy.[xix]
• Technical and technological proficiency makes it easier to 'label' conditions as mental illness. This interacts with worldwide readiness to look for 'magic bullet' solutions to increase our dependence on 'artificial support mechanisms'.
• The (cyclical) trend towards extreme conservatism of political institutions exacerbates the inherent tendency to 'blame the victim'.[xx]
• We will be facing growing numbers of people incarcerated for 'anti-social behaviours', with more and more pressure placed on diminished support structures for those who do not conform or who are designated as 'problems'.
• Australia is experiencing a process where we are underfunding the deinstitutionalisation of specifically equipped mental health facilities only to see many people "re -institutionalised " in inadequate and unsupported boarding houses or incarcerated in ill-equipped prisons." It is a process of problem shifting rather than problem solving.
• There are substantial pressures on people, previously institutionalised, to find employment, obtain and retain housing and participate in the community. This is a result of policies that over-emphasise individualistic approaches to rehabilitation and support.
• Government policies and program practices have the effect of reducing the amount of support available to people 'at risk' of mental health difficulties. Only those people with the most severe behavioural manifestations of disturbance get access to 'expert' assistance in a crisis, and then only some of them.

A new form of 'blaming the victim' thinking is inherent in the philosophy of 'mutual responsibility'. Because it accompanies reduced opportunities to obtain secure employment and growing uncertainty about the future generally, people seeking government assistance that used to be their right are now made to feel that they must earn the privilege of State support.

Prime Minister Howard's Federation address on the 28th of January in Brisbane left many human service workers wondering whether his concept of "mutual responsibility" knew any bounds. Howard foreshadowed decreasing young people's unemployment payments if they "continued to remain illiterate and innumerate". Had he bothered to ask, any educator could have told him that no young person wilfully and deliberately sets out to fail to learn how to read and count. But observers should not be surprised by the Prime Minister's utterances on young unemployed people - they are unfortunately part of the fine charity tradition of expecting the marginalised to sing for their supper.

Australia's eager pursuit of 'privatisation' and 'small government / (aggressively) big business' begs the question of what governance means. This impacts on the types and levels of service that the individual receives, as well as affecting the way citizens perceive their relationship with the structures of Government. Prime Minister Howard's desire to create a "share owning democracy" has moved the concept of citizenship from one where we all shared the common wealth to one where some now own shares in financial entities we once owned collectively.

Associated with this is a 'can do' approach to decision-making, where alternative views are over-ridden by the tough let's get the show on the road' ethos. Australia seems to have lost its 'laid back innocence'. Where we once placed store by our ingenuity, 'mateship' and ability to tackle problems in commonsense, practical ways we are now so keen to posture as a player on the world scene that we eagerly fall prey to the 'quackery' of the instant fix or magic bullet.

Above all, the nation has lost its passion about injustice. Where Australia was until quite recently renowned for its 'fair-go' mentality, this is now seen as weak-kneed and pandering to the less worthy elements of society. This is accompanied by 'shoulder-shrug' apathy about deliberate and systemic misleading statements on the part of political leaders and policy-shapers. The common public response to yet another broken political promise is a resigned, "what can you expect?"

Acknowledged even by Tom Kewley,[xxi] there has been an essentially conservative thread running through the provision of income support provided by the Australian welfare state since Federation. This is so despite Australian welfare provisions being described by European welfare experts in the early part of this century as socialism without ideology. The first income support payments made by the Federal Government in 1909 were age and disability pensions and until 1927 they were paid by Treasury.

Asian Australians (until the 1940s) and Aborigines (until the late 1960s) were not entitled to payment of these pensions. At the turn of the century, the age of entitlement of 65 for men closely approximated the average age of death. In order to qualify for either the age or disability pension one needed to establish oneself as being of "good moral character". Such requirements remained part of the Social Security system until 1973, when Bill Hayden as Minister for Social Services in the Whitlam Government removed this requirement.

In relation to unemployment payments, the need for applicants to establish their essentially worthy nature has been starker. During the 1930s Depression, in order to qualify for the Susso, men had to undertake make-work schemes designed by local authorities. In many places they were also required to move from town to town each fortnight to get their rations. In the 1970s Nugget Coombs and others re-established such make-work for the dole schemes on Aboriginal communities, where they continue to this day as the Community Development Employment Program (CDEP).

Concerned by the prospect of fully trained soldiers returning home to unemployment after fighting for King and Country, and influenced by the experience of the Great Depression, Prime Minister Ben Chifley set out to ensure there would be work for nearly everyone and unemployment benefits for those for whom no work could be found. The 1947 Social Security legislation brought together in one bill many payments such as child endowment, widows, sickness and unemployment that had gradually been added to the age, and disability payments. Even though this legislation was regarded as progressive and comprehensive for its time, each applicant for payment needed to establish an individual eligibility that depended not only on their fitting the main criteria but also meeting other social requirements.

Apart from being of good moral character, the unemployed person had to meet the work test that required them to be fit, able and ready for work. Most of the time, from the end of the Second World War until 1974 the level of unemployment remained around 1% and the unemployed did not figure largely in the scheme of things. But when unemployment, and particularly youth unemployment, began to climb in the last year of the Whitlam Government Clive Cameron and Bill Hayden resorted to clichéd generalisations about "dole bludgers" and "work shy lion tamers".

The Fraser Government also sought to blame unemployed people themselves for the failure of the state and industry to find a use for their labour or to educate them for the work that was available. It was in this period that unemployed people became vilified as "dole bludgers".

Whilst the attacks on the unemployed and particularly the young unemployed were becoming ever more shrill, there were continuing efforts to improve the comprehensiveness and generosity of other income support provisions. Given these and the Arbitration Commission coverage, Australia could, as Professor Frank Castles suggested, reasonably be described as "a Worker's Welfare State".[xxii]

In the early years of the Hawke Government, there was continued expansion in both income support and disability services, driven by Don Grimes as Minister for Social Security. Brian Howe's appointment as Minister for Social Security coincided with the start of the cutbacks in human service provision and particularly income support. It was no coincidence that unemployment was rising. The Department of Social Security in its 1986 Annual Report boasted: "In short, there was a substantial increase in the number of unemployed over the year but a substantial decrease in the number of unemployment beneficiaries as a result of increased targeting."[xxiii]

The rate of the youth unemployment benefit did not rise during Fraser's seven years in office. Hawke initially increased unemployment payments to young people but was soon to lose interest in restoring the real value of the benefit level they had experienced under Whitlam. The Labor Government increased targeting (tightened eligibility) and collapsed several payments into one in a way that ensured the lowest amount was paid. Usually it was the young who missed out. Howard replicated this technique with his Common Youth Allowance and his merging of the Aboriginal Study Scheme into Austudy in 1998. Also in that year Howard abolished unemployment payments to 16-18 year olds. The replacement Youth Allowance effectively withdrew this form of income support from 46,000 young Australians.[xxiv]

During the late 1980s, as the rate of unemployment rose there emerged signs that voters were taking the threat of unemployment seriously. Labor leaders stepped up the vitriol in their attacks on the unemployed and started talking about "reciprocal responsibility". In the wake of the Green Paper, Working Nation, under Labor this meant that in return for income support those who were unemployed were required to do more than pass the work test: they had to undertake training or some other approved activity. Those who remained unemployed after 18 months would be offered work.

Labor had considered but rejected a general return to the 1930s Susso type work for the dole schemes. In1998, Howard, influenced by the New Zealand conservatives' introduction of a Work for the Dole scheme began to implement his thesis on "mutual obligation". His actions have replicated the cutbacks the New Zealand conservatives have made to their arbitration and welfare systems. Governments on both sides of the Tasman have been influenced by the American "Workfare rather than welfare" rhetoric and by the fear of "dutiless rights" articulated by the British Conservative David Green.[xxv]

Howard's latest attack on social welfare provision by decreasing the amount of benefit paid to illiterate and non-numerate young applicants for unemployment payments derives out of that deep conservative distrust of the poor. Whether it is expressed in terms of "dutiless right", "reciprocal obligation", "mutual obligation", "getting something for nothing" or in the Australian vernacular "bludging on the system" it amounts to the same thing.

It is not surprising that Howard specifically singled out the young illiterate people - he did that with his Work for the Dole scheme before preparing to extend it to older Australians.[xxvi] Howard knows that political attacks on the young go down a treat with many older Australians.

There is a different order in the Howard Government's recent decision to specifically target young people with reading and learning difficulties. The question must be asked as to who will benefit from this policy direction. Most analysts agree that it will cause more suffering for the least skilled, least schooled, least powerful, migrant, indigenous, marginalised, intellectually disabled and poorest members of this society.

They are the group least likely to vote Liberal if they vote at all. What ever happens to them they are also the group least likely to benefit from the educational and technical revolutions of the next millennium.

The policy is interesting in another regard and that is the class-based interpretation of work. In Australia since the 1940's applicants for unemployment benefit have had to show a willingness to undertake any form of work. This new policy ignores the fact that many jobs do not need to be done by people who are able to read, write or count. The demand for workers to do those jobs may have decreased but such jobs still exist in considerable numbers. This policy downgrades the dignity of all labour done by people without reading skills.

Michelle Grattan may be correct when she says that this policy will generally be well-accepted in middle Australia.[xxvii] But if she is correct, then middle Australia is missing something that well may yet come back to bite their children. How long will it be before one of the requirements for unemployment benefit is computer literacy (to cope with the technological revolution), university level numeracy (to cope with increasingly available statistics), literacy in an Asian language (to cope with tourism) and a PhD in Economics (to cope with globalisation)? It is even possible that Howard, being the great admirer of sport that he is, will in the wake of the Olympic scandal and our cricketers moon lighting as weather forecasters insist that applicants for unemployment benefit are also ethically literate.

Sadly, then, we are entering a new era [xxviii] of carelessness about the pain of other people. Many explanations are advanced as to why this should be so. The 'bottom line' economic rationalist' [xxix] approach to 'efficiency' has helped to focus attention on process rather than people, and on transactions or throughputs rather than results or outcomes. Prolonged uncertainty about the stability of economic systems (local, regional and worldwide) has contributed to a 'get it while it lasts' mentality. That this is superimposed on a long period of 'greed is good' thinking has exacerbated the feeling among many marginalised people that they have no legitimate place in 'the new order'.

It is possible also that the perceived failure [xxx] of the Church and established religions to offer stabilising certainty where so many social structures are shaky and mistrusted has contributed to the sense of loss of power among those who lack adequate protection of their rights.[xxxi] Arguably, ethical and moral leadership is scant. Increasing government sensitivity about scrutiny, let alone criticism of its policies and actions has led to polarisation of public debate. The attitude among Ministers of State is increasingly one of 'those who are not 100% for us are entirely against us.' This stymies constructive analysis of options.

The concept of senior public servants providing their Ministers with fearless advice belongs to a bygone era. Alongside privatisation of common assets there is contract (insecure) employment even at the top. So Ministers are now told by their senior "public servants" what the Minister wants to hear. This usually is what the Minister's staff told the minister in the first place. The job of policy analysis has changed from reviewing possible options to becoming part of a mindless cheer squad. How else would you explain the Prime Minister's announced policy of cutting the unemployment benefit payments to young unemployed people with literacy and numeracy difficulties? This can only be to disguise the failure of Centerlink (largely because of staff downsizing) to refer enough of the unemployed to out-sourced literacy training service providers with whom the Government had awarded $143 million dollar contracts.[xxxii]

Moreover, the media have for the most part opted out of independent analysis, being either captive of political propaganda machines, or pandering to popularist preoccupation with trivia.[xxxiii] An unintended by-product is to expose vulnerable people to graphic examples of bizarre and misguided behaviours that are accorded unwarranted significance by the popular media. Media-fed fear of group and personal violence makes many people wary of assisting anyone showing signs of 'unusual' behaviour. In the past a kindly stranger might offer just the right reassurance at the critical moment. Now, general avoidance of involvement in the face of relentless government attacks on powerless/marginalised people and exaggerated fears of legal 'duty of care' liability means that those of our community who suffer feelings of alienation and 'persecution', have their irrational concerns exacerbated.

Human rights policy, legislation, guidelines and protocols have too readily been interpreted as exonerating irresponsible behaviours. This has led to a 'backlash', such as demonstrated in the recent Queensland and Federal election support for the so-called 'One Nation Party'. Even among more thoughtful opinion leaders, there is a call for greater attention to the 'responsibilities' that go with rights.

The ongoing unwillingness of our national government to say 'sorry', on behalf of the nation, for inhumane policies and practices in Aboriginal affairs over so many years has prolonged a sense of guilt and anxiety and stands in the way of meaningful 'reconciliation'.

Where once Australians might have turned to the United Nations or International Labour Organisation Covenants and Conventions as a guide to appropriate minimum standards we now look to the Thatcherite Charter of Service on the walls of the local "cost less" supermarket for inspiration. We present here but two examples of the outworking of this 'philosophy'. We have a Prime Minister who, confronted by the possibility of our closest neighbour (after Nuigini) getting Independence from the country which invaded it in 1975 plugged for its continuing to be part of Indonesia "because an independent East Timor might mean we would have to increase our foreign aid." The second example is that John Howard, in spite of the Wik and Mabo cases in the High Court, seeks to maintain the concept of terra nullius by promoting a new preamble to the Constitution which refuses to recognise indigenous Australian's prior ownership, acknowledging only prior occupation. Australia's much-vaunted 'multiculturalism' is again under scrutiny. Although it may be that few Australians share the extreme xenophobia of 'One Nation' Party immigration policies, it is incontestable that sustained high unemployment, contraction of many social welfare policies, and uncertainty about future directions are combining to make many Australians question the nature of our 'national identity'. The debate about an Australian Republic may be feeding the sense that 'core values' could be at risk.

In our view, even the sketchy analysis offered here adds up to Australia being a 'care-less' society. By this we mean one in which, as a generalisation, people are less inclined to help each other, where formal social supports are decreasing, or are under threat, and a society that puts particular strain on those of its members who need emotional support. It is the argument of this paper that to redress this carelessness requires far more attention to localised, 'neighbourly' support structures and services, of the 'being there/ being with' kind, than is recognised in the National Mental Health Strategy and Mental Health Priority Plans currently in place.

This phrase intentionally has two meanings. Appropriately, what for convenience is called 'The National Mental Illness Inquiry' [xxxiv] made an effort to determine how we could know 'what counts' in statistical and operating policy terms as mental illness. There is still debate about the exact extent of diagnosed and diagnosable mental illness. It is sufficient for our purposes here to note:

1. the National Inquiry's conclusion in its 1993 report that at least one million Australians over the span of their lives experience symptoms of serious mental illness;[xxxv]
2. recent data from the Australian Psychiatric Disability Coalition showing an exponential increase in suicide attempts among both young and older people;[xxxvi]
3. evidence presented to a Senate inquiry on the dramatically increasing prescription of anti-depressants by Australian doctors [xxxvii]; and
4. expressions of concern by authoritative bodies such as the Schizophrenia Fellowships of Australia, the Richmond Fellowships, and the Association of Relatives and Friends of the Emotionally and Mentally Ill about the growing numbers of people unable to access mental health services.

The second meaning of the sub-heading relates to understanding and appreciating the things that count - have meaning - for people who have a diagnosed mental illness. The National Mental Illness Inquiry demonstrated unequivocally the necessity of stronger community support services (centred on the principle of 'being with') at a time of 'deinstitutionalisation'. Alarmingly, the Inquiry found diminishing community supports just at the time when the greatest pressures were being placed on families, local communities and neighbourhoods to absorb people who were being 'returned to the community' from institutional care. It was of especial concern that necessary support was not available to those people who were still unstable following mental illness because of short hospital stays and lack of time to tailor medication to individual requirements.

The Inquiry was positive about the basic policy of deinstitutionalisation: there was incontrovertible evidence that at the very least hundreds, if not thousands of people labelled as 'mentally ill' were inappropriately housed in facilities that still operated on the 'contamination' principle.[xxxviii] But wholesale movement of people who may have spent all of their formative years in a 'total institution' [xxxix] has placed enormous, sometimes unbearable strain on far too many families, carers and community organisations which are usually underfunded for their demanding role.

Governments share a propensity to gather all the kudos they can muster from engaging in the rhetoric about families. The present Commonwealth Government, however, constantly acts in ways that undermine families. Removing government and community based support mechanisms that might enable families to help relatives in need and cutting back income maintenance and other social welfare - particularly disability and unemployment - programs are examples. In January 1999, the Government conducted a National "consultation" on disability advocacy services during which central office operatives pushed for the establishment of specialised agencies to "promote the interests of families". At the same time, if the Government accepted the report then it would result in the de-funding of several legal advocacy programs that sought to promote the rights of individuals with disabilities. If the Government were serious about promoting the interests of families then it would have increased funding for advocacy services over all rather than reallocating priorities within an existing tight advocacy budget.[xl]

In its follow-up inquiry into mental health services in Victoria, the Human Rights and Equal Opportunity Commission [xli] found that many individuals and organisations making submissions to the original National Inquiry were fearful of retaliatory action by Government agencies. Conducting its hearings in what it described as 'a climate of fear' the Commission experienced great difficulty in reconciling Government claims of dramatic improvement in mental health services with evidence from many people of high repute in the non-government sector of 'bullying' and threats of withdrawal of funding.

This replicates what the National Inquiry found in its examination of the people with their 'finger on the pulse' of the mental health status of Australia. Dismissed as 'anecdotal evidence' by the then Federal Minister for Health, the greatest impact of the HREOC initiative was to draw on the personal experiences of 'consumers' and providers of mental health services. In all, some 1600 people and organisations gave accounts of the practical consequences of voluntary or mandatory exposure to 'the mental health system'. These people 'stood up to be counted' in a very real way, some of them taking considerable risks of increased stigma, censure, or even punishment from the agencies on which they were dependent.

The clear message from the evidence presented to the HREOC National Inquiry is that Australian Governments, separately and collectively, have wittingly or unwittingly transgressed many if not most of the fundamental principles of international covenants protecting the rights of people with mental illness. Perhaps even more significantly, there was little sign of Australian commitment to World Health Organisation protocols designed to promote mental health in a positive, proactive way rather than simply react to mental illness. Indeed, there was a new cloud hovering over what was euphemistically designated as Australia's mental health system. Government funding was increasingly being directed towards quite limited and limiting clinically focussed services for only the most obvious and apparent 'serious mental illness'.

In both meanings of the expression, 'standing up to be counted' in Australia as it heads to a new millennium requires a reassessment and reappraisal, 'without fear or favour', based on better counting (statistics) of need and improved analysis of the benefits and costs of meeting that need.

One of the features of a caring society is its ability to 'be with' people in a fragile situation. 'Just being there' remains as one of the cornerstones of all of the services that consumers judged as successful in the National Mental Illness Inquiry. The people interviewed meant by this that they found real benefit in having access to services and individuals that would take them as they were, not trying to 'cure' or 'reform' them, but providing what used to be known non-pejoratively as 'asylum'.[xlii]

The principles of 'sanctuary' and 'asylum' have an honourable tradition. At least from the time of the first 'hospitallers',[xliii] religious orders have not only provided hospitals and hospices for the physically injured, sick and dying, but have also offered 'safe haven' for those people who are persecuted or at risk because of their 'unnatural' behaviour.[xliv] Many people who have been diagnosed as having a 'mental illness' have attested to the importance of such 'asylum', both in coming to terms with their purported illness and in handling the process of 'recovery' and rehabilitation. In this sense, religious and charitable bodies have 'been there' for people who need time out, whether or not this is associated with some form of spiritual succour.

Going beyond this, however, the movement towards psychosocial rehabilitation within therapeutic communities, initiated in Britain just after the Second World War [xlv], placed renewed emphasis on mutual support within 'protective shelter'. This is not so far removed from some of the original notions of sanctuary.[xlvi]

The being with' and 'being there' favoured in topical colloquialism seem to share this common heritage. Again, here is recognition that human beings need various forms and types of contact. Intimate sharing is not for everyone. Especially where trust has been tested and confidence in personal relationships is low, the succour offered by 'agenda-free befrienders' may be of priceless benefit. We believe that the next wave of strategies to promote the mental health status of Australia must place strong emphasis on the development of mechanisms for 'being with' people who experience emotional and psychological trauma. This requires an acknowledgement from Government that you can't "be there" if you've also got to be in six other places simultaneously.

The following are among crucial requirements for improvement in community, so as to recover the opportunities for 'being with' people having mental health needs:

• Establishment of places of sanctuary or asylum in each neighbourhood, using the model of the 'safe house' program adopted by schools in most states. It would be necessary to identify one or more mental health organisations that would undertake:

1. the selection of families able to offer suitable 'house of personal retreat' facilities
2. supervision of the facility
3. advice and support to the families offering the service
4. links with expert mental health services for treatment and rehabilitation where needed.

• The funding and appointment of 'linkage workers' for each municipality/shire or other agreed population area. These workers would be trained and selected to provide:

1. an ongoing community development focus for initiatives to improve positive mental health within local communities,
2. a co-ordination point for the 'house of personal retreat' program,
3. information and awareness-raising services across the municipality/shire
4. expert advice and support for evaluation and program development as other opportunities arise.

If our analysis is correct, then Australia has to move quickly to build or regain communities of high mental health status. We note that there is plenty of compassion and concern on which to build. What is at stake is to harness the good will of communities that are nonplussed by the 'care-less' dictates of economic rationalism.

We suggest that the following are fundamental elements in achieving 'social maturity':

• valued membership of caring and compassionate communities;
• leadership that articulates and lives out principles of high ethical standards, social cohesion and respect for difference;
• social institutions that give both moral and practical support for community as the essential underpinning of all individual striving; and
• both formal and informal mechanisms for 'being with' people who are troubled in their personal identity and interpersonal relationships.

Since the time of the HREOC National Mental Illness Inquiry, there has been sporadic interest in 'the issue' of youth suicide, and most recently the Prime Minister has launched an initiative to promote early intervention for young people at risk of homelessness. It is impossible not to be sceptical of the proscriptive morality that seeps through all the pronouncements about 'strong families' as the panacea for all social problems.

If we are to rely on family as the foundation of a mentally healthy society, then it will serve us well to understand a little of the dynamic of Aboriginal communities. For it is inherent in the way that Aboriginal society naturally organises its affairs that family and community are pre-eminent. As elaborated in the HREOC report, often 'community' denotes cultural and/or linguistic affinity. This is exemplified most graphically in the particular issues of identity facing Aboriginals and members of the signing Deaf community.[xlvii]

Whilst necessarily only a broad overview, and suffering the deficiencies of all simplistic generalisations, the following are offered as key features of the approach taken by the Anangu, the Aborigines of the cross-border region of Central Australia.[xlviii]

• Care is provided by and within the family (walytja) for as long as is possible.
• All social activity revolves around kinship relations, which are inclusive rather than exclusive. It is necessary to live with or be near your family, and have frequent and meaningful contact, to learn about your social place and relatedness.[xlix] This can be very difficult when care services are scattered, inappropriate and unresponsive to Anangu requirements.
• The community accepts responsibility for assisting families to support people needing care.
• The carer role is acknowledged as a natural and highly valued part of family and community responsibility.
• Continuing participation in events of great significance to community life (meetings, funerals, sporting events and so on) is regarded as a priority.
• Because Anangu also give priority to remaining on their own lands, support services have to be provided in flexible and culturally appropriate ways. The malparara system, whereby Aboriginal and non-Aboriginal workers combine to share skills, perspectives and cultural understanding, is proving to be highly beneficial. The Anangu malpa (friend and helper) is the 'go-between' for the non-Aboriginal worker, providing the entrée to indigenous protocol and cultural practice. This reflects the principle that Anangu 'own' the identification of and response to the needs of their communities.

Even this brief analysis surely demonstrates the urgent need to reorient mental health policy and services around better understandings of the essential features of mutually supportive, sustaining communities. It will be truly tragic if Australia enters a new millennium pursuing programs that simply react to crisis when so much can be done to avoid harm in the first place.[l]
 

1. A. Human Rights and Equal Opportunity Commission (HREOC) - Human Rights and Mental Illness: Report of the National Inquiry into the Human Rights of People with Mental Illness (2 Vols), Canberra, Australian Government Publishing Service: 1993. [Abbreviated as The HREOC Report.] See also HREOC Report of the Reconvened Inquiry into the Human Rights of People with Mental Illness (Victoria), AGPS, 1995. 
    
   B. P Eisen and K Wolfenden - National Mental Health Services Policy. The Report of the Consultancy to advise Commonwealth, State and Territory Health Ministers, AGPS, Canberra, 1988.
    
2. Among notable exceptions is Hugh Mackay, whose regular newspaper columns examine many facets of 'the mental health of the nation' (our term, not his). Mackay's book 'Reinventing Australia: The Mind and Mood of Australia in the 90's', Pymble, Angus and Robertson, 1993 offers many insights into what we call 'the social condition'.
    
3. Belated, but welcome recognition of this fact comes in a Melbourne Age report of plans by the Premier of Victoria, Jeffrey Kennett, "to establish a Commission of Cause, comprising experts from across the country, to examine how the causes of depression across all ages can be tackled." [Michael Gordon, 'The Age' Melbourne, 6 March 1999, p.8.]
    
4. Commonwealth and State Health Ministers have agreed to a Second National Mental Health Plan, to run for five years from July 1998. See Australian Psychiatric Disability Coalition (1998) - A Framework for Action: Proceedings of the 'Innovative Partners' National Forum, Canberra: 10-11 October 1998.
    
5. Kewley, T.H. [1980] - Australian Social Security Today, Sydney University Press.
    
6. See Tomlinson, J (1998) "Depending on You: Let's get Basic about income and employment." Paper given at the 5th National Conference on Unemployment, Melbourne, 1-2 October.
    
7. As but one example, note the lack of comment about factors contributing to positive mental health in the report entitled The Health of Young Australians: a national health policy for children and young people (AGPS, 1995) which was endorsed by the Australian Health Ministers Conference of 15 June 1995.
    
8. Human Rights and Equal Opportunity Commission, 1993 and 1995 - loc cit.
    
9. Human Services Victoria (1999) - A Stronger Primary Health and Community Support System: Demonstration Projects Request for Proposals, Melbourne: Victorian Government Department of Human Services.
    
10. Commonwealth Government Social Welfare Commission [1976] - Australian Assistance Plan, Canberra: Social Welfare Commission.
     
11. Commission of Inquiry into Poverty [1975] - Poverty in Australia First Main Report, AGPS: Canberra.
     
12. Fincher, Ruth and Nieuwenhuysen, John (Eds) [1998] - Australian Poverty: Then and Now, Carlton South, Melbourne University Press. See also Steketee, M, (1999) "Poor fella our countrymen." The Weekend Australian, Focus Section, pp.22-23.
     
13. ABS (1996-1999) Labour Force. Cat. No. 6203.0, Altman, J. (1997) "The Achievements and Limitations of the CDEP Scheme - A 20-Year Perspective." Social Security Journal. Canberra, December.
     
14. See, for example, the report of the Prime Minister's Task Force on Youth Suicide (available on the Department of Health and Family Services Web site) and data collected by the Australian Council on the Ageing.
     
15. See the Web site of the Australian Psychiatric Disability Coalition (APDC) for the report of the APDC National Forum 'Innovative Partners' held October 1998. Note especially the document, 'A Framework for Action'.
     
16. See, for instance, Adrian Rollins [1999] - 'Pill-taking causes less of an headache', "The Age" Melbourne, 30 January. Refer also to endnote xxviii.
     
17. McLennan, W. & Madden, R. [1997] The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. ABS & Australian Institute of Health and Welfare, Canberra, Kilham, R. [1995] Federal Government Funding for Indigenous Health. Access Economics, Canberra. Crough, G. (1993) Visible and Invisible: Aboriginal People in the Economy of Northern Australia. NARU and Nugget Coombs Forum for Indigenous Studies, Darwin.
     
18. Information supplied by Dr Joan Clarke, Executive Director, Prahran Mission.
     
19. As but one example, the Rev. Bill Cruse, interviewed on ABC Radio National on 24 December 1998, said that he had not received a single response to approaches he had made to 50 of Australia's top companies, seeking support for the Exodus Foundation's work with poor and homeless people.
     
20. Ryan, W. [1971] Blaming the Victim. Vintage, New York
     
21. loc cit
     
22. Castles, F. [1994] "The Wage Earners Welfare State Revisited:" Australian Journal of Social Issues. Vol. 29, No. 2.
     
23. Department of Social Security (1987) Annual Report 1986-87. AGPS, Canberra. p.99
     
24. Horin, A. [1998] "Dole cut for thousands of young jobless." Sydney Morning Herald. June 29, p10.
     
25. Green, D. [1994] Community Without Politics. Institute of Economic Affairs, Health and welfare Unit, London.
     
26. Steketee, M, [1999] "Tougher benefit tests for adults." The Weekend Australian. 27-28th Feb, p.3
     
27. Radio National Breakfast Program, ABC, 29 Jan 1999.
     
28. Even the most superficial reading of history will indicate that our current societal insouciance is far from unique. What makes the present situation so significant is the loss of stabilising social structures: this is the burden of the argument of this essay.
     
29. While it can plausibly be argued that economic rationalism dates back at least as far as Adam Smith and Thomas Malthus, it is only since Milton Friedman that it has come to be associated with 'slash and burn privatisation'.
     
30. Whether there is in fact a lessening of interest, involvement and concern on the part of the institutions of established religion is a matter worthy of study in its own right. The 'church and life' studies known to the authors do not adequately address this issue.
     
31. This can be through lack of capacity on their own part, or diminution of advocacy, monitoring and control procedures that were previously accepted as a community responsibility.
     
32. Armitage, C. [1999] "Read for the dole fills in $14m cost hole." The Weekend Australian. 13-14 February, p3.
     
33. Sociologists and commentators seem divided on whether this preoccupation is in the face of despair about understanding complex political, social and economic forces, or is a manifestation of the hedonism that has historically accompanied periods of social upheaval.
     
34. Human Rights and Equal Opportunity Commission, Human Rights and Mental Illness, Report of the National Inquiry, loc cit.
     
35. Serious mental illness is defined as prolonged and persistent mental confusion that substantially impairs a person's capacity to live independently in a personally fulfilling way.
     
36. This is a compilation of data from the Australian Bureau of Statistics, The Australian Institute of Health and Welfare, and results of surveys conducted by APDC members.
     
37. Pamela Bone in a feature article in The Age (Melbourne) 24 December 1998 reports a 47% increase in the use of anti-depressants in Australia over the last ten years.
     
38. Again, this is our shorthand for the late C19th/ early C20th approach to institutionalisation that presumed 'mad' people would contaminate - or even infect - others and must therefore be locked away. This amounted to an 'out of mind, therefore keep out of sight' variation of the well documented 'out of sight, out of mind' phenomenon.
     
39. See Goffman, Erving [1961] - Asylums, NY: Doubleday-Anchor.
     
40. Department of Health and Family Services, [1998] National Disability Advocacy Program Review: Draft Steering Committee Report, Canberra, AGPS, August.
     
41. Human Rights and Equal Opportunity Commission [1995] - Human Rights and Mental Illness, Victoria: Report of the Reconvened Inquiry into the Human Rights of People with Mental Illness (Victoria), Canberra, Australian Government Publishing Service.
     
42. The newer connotations of asylum with involuntary withdrawal of rights, privileges and responsibilities associated with citizenship seems likely to derive from social/ political rather than medical constructs of mental illness. See, for example, Thomas Szasz [1974]'The Myth of Mental Illness: Foundations of a Theory of Personal conduct', New York: Harper and Row.
     
43. Generally taken to originate with the C12th military religious order founded by the European crusaders in Palestine.
     
44. It's worth noting that the very idea of what is and is not 'normal' had little significance until the birth of modern statistical method, and especially psychometrics, attributed to R.A. Fisher.
     
45. Possibly the best representation of this movement in Australia lies in the work of the Richmond Fellowships, now operating in all States and Territories.
     
46. The 'Safe House' movement can be seen as an extension of this same concept, applied of course in a particular way to suit specific circumstances.
     
47. See especially Chapters 20 and 23 of the HREOC report.
     
48. Ngaanyatjarra Pitjantjatjara Yankunytjatjara [NPY] Women's Council Aboriginal Corporation [1998] - Consultation Report: Older Indigenous Australians with Long Term Disability (Prepared for the 1999 International year of Older Persons Research Consultancy), Alice Springs, December.
     
49. NPY Report, p. 29.
     
50. There is a 'glimmer of hope' in the recently reported intentions of the Premier of Victoria to 'work on the causes of depression, drug-taking and suicide'. See endnote iii for full reference.
     

* * *

Special thanks are extended to Geraldine Gerrish, author of the NPY Women's Council report quoted in this article (see footnote xlvi) and Angela Lynch, Mental Health Project Officer for the Council for their assistance. The comments and suggestions of Dr Joan Clarke, Executive Director of the Prahran City Mission and Kris Chapman, Assistant Manager Community Care of the Victorian Deaf Society are greatly appreciated.

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