Richard Trembath examines the increasing demand for mental health services in Australia.
I was a stricken deer that left the herd
Long since; with many an arrow deep infixed
My panting side was charged, when I withdrew
To seek a tranquil death in distant shades . . .
I see that all are wanderers, gone astray
Each in his own delusions;
William Cowper, The Task, Book Three, published 1785.
More about William Cowper later. During the COVID pandemic there have been many reports of an increased demand for psychological and counselling services. This enhanced demand is the result, it is claimed, of the stresses induced by lockdown, social restrictions and the like. The following is but one of many instances I could have chosen:
A spike in demand for psychology services across Australia has seen waiting times triple in some regions, with a number of providers saying they are fully booked until next year Mental health researchers at the Black Dog institute . . . found that up to 80 per cent of people felt their mental health had been affected by the coronavirus pandemic, causing them to consider seeking care.[i]
Yet well before COVID, recourse to mental health practitioners had grown sharply in Australia. The latest official data shows the marked uptake in the provision of these therapies. In 2009-2010, 6.2% of Australians accessed Medicare-subsidised mental health specific services. A decade later this had risen to 10.7% or 2.7 million people. 45.3% of these services were provided by psychologists, 30.6% by general practitioners and 20.3% by psychiatrists.[ii]
Even if you are in the happy position of not requiring such treatment you probably have noticed the ubiquity of notices in the media which provide contact details for Lifeline, Beyond Blue and similar organisations. Such advice follows an article which deals with trauma, an alleged or actual suicide, sexual assault, domestic violence etc. I provide two brief examples:
Need to talk to someone? Don’t go it alone. Please reach out for help . . .
Are you anxious? Take the Beyond Blue quiz to see how you’re tracking and whether you could benefit from support.[iii]
And from a podcast in the Australian edition of the Guardian:
In Australia, the crisis support service Lifeline is on 13 11 14 and the national family violence counselling service is on 1800 737 732. Other international helplines can be found via www.befrienders.org[iv]
In this article I examine how what could be called, without excessive drama, a revolution in the demand for, and provision of, mental health services in Australia has occurred. What has happened in Australia has also happened in much of the developed world, but I cannot explore these international dimensions here. Even without that restriction, the subject is huge and I must omit much of interest. If readers are interested in issues which they feel I have skated over, they are welcome to contact me.
Definitions are necessary. Psychiatry in Australia is a medical speciality, studied as a postgraduate qualification. Without such credentials one cannot call oneself, or practice as, a psychiatrist. The loose use of ‘counselling’ and ‘psychology’ can cause some confusion. ‘Counselling’ is the broader term and covers a wide range of training programs, some falling within the realm of complementary and alternative medicine. Counsellors do not have to be formally trained, though many are. ‘Psychologist’ is more specific. As with psychiatrists, medical practitioners and nurses, psychologists are regulated by a discipline specific National Board and over that by the Australian Health Practitioners Regulation Agency (AHPRA). Psychologists, whose numbers have leapt in recent years, are doubly endorsed by the state as their services receive a government rebate – something to which other counsellors are not entitled. Governments at two levels have attempted to clarify these differences for the benefit of the public. Thus, in Victoria we have the Better Health Channel.[v] The Federal government conducts Healthdirect Australia and it too issues information sheets which explain the distinction between psychiatrists and psychologists, what services each offer, choosing the right counsellor, and, importantly, which practitioners attract Medicare rebates.[vi] These information sources are crucial to ensuring general health literacy though there is still work to be done in increasing the pick-up in lower socio-economic groups.
In 1993, Australia adopted its first National Mental Health Plan. It was recognised that demand for mental health therapy greatly exceeded the capacity of existing services and that this nation needed to prioritise this area, including funding. This marked a further adjustment of the federal-state nexus in the public health area, as has in many ways occurred with the National Drug Strategy (NDS). Non-government organisations are an essential part of a new system, Beyond Blue being one of the most prominent, partly because of its uncanny ability to attract former politicians such as Jeff Kennett and Julia Gillard to chair it. Getting dumped at an election does not close off all doors, it seems. The first National Mental Health Plan has been succeeded by others and despite the inevitable strains of COVID and on the spot adaptations such as telehealth (not loved by all psychologists or their clients), I think that the strategy is still widely supported by its stakeholders. For one thing, it has attracted less academic criticism than the NDS has.[vii]
Why did mental health treatments become public health priorities in Australia and elsewhere in the 1990s? As one would expect the answer is complex and, in some ways, speculative. I would suggest starting four decades before, in the early 1950s, when drugs such as lithium and chlorpromazine became the first pharmaceutical products to counter manic depression (now bipolar disorder), abrupt mood swings and psychotic episodes.[viii] For those with less severe complaints, the benzodiazepines – Valium and Librium aka ‘benzos’, ‘Mother’s Little Helpers’- were produced, their addictive qualities only becoming known later.[ix] British medical historian, William Bynum, argued that:
By the early 1960s, community psychiatry was the buzz word, as psychiatric patients were to be treated as outpatients, with the belief that they would be able to live more-or-less normal lives if they simply took their medicines. For people with mild depression or anxiety, Librium and Valium came on the market. Medicine seemed truly to have, or shortly to have, a pill for every ill.[x]
This is not exactly contemporary practice, nor much to do with counselling as we understand it today. However, it marks a step in the retreat from institutionalisation of the mentally ill. Gradually, it was accepted that such disorders could be overcome or at least integrated into a ‘normal’ life.
But in Melbourne in the 1970s who went to a psychologist? Some people did, such as the clients of the then well-known Ronald Conway, author of the now largely forgotten The Great Australian Stupor. But this was uncommon. You went to a psychiatrist if you were severely mentally disturbed. Huge institutions had been developed to cater for those considered incapable of continuing life on the outside – either for their own sake or others. My father, a psychiatrist, had worked at one of these in Kew. But, as noted previously, these had passed their heyday. Psychology was traditionally located in industry, government departments, the military, and in education. In the first three categories, the practitioner was best described as working in vocational or industrial psychology, not clinical. Later it spread to hospitals and community health practices and later still to the private clinics with which we are familiar.[xi] This spread was not rapid though. Many media articles, some of them stunningly superficial, talk of the traditional Australian response to trauma, abuse and mental health issues as ‘grin and bear it’, ‘suck it in’, ‘don’t talk about it’. Apparently, this old-fashioned attitude is especially true of men, even today.[xii] Finally, in the 1970s there were precursors to the rise of mental health therapy, which are interesting in their own right and worthy of further study. Marriage guidance counselling was one of these, a government endorsed approach, to what were seen as social threats: divorce and family break-up. Another was the popularity of psychological programs such as Transactional Analysis, with its group work and role play, and which was taken up by church organisations and other bodies looking to improve co-operation and trust amongst members.
Without claiming to be exhaustive, and not ranking these in any order of importance, I think the following factors have also been significant in the growth of psychology as a socially acceptable, shame free, service.
- Prominent individuals, such as politicians, sporting stars or television celebrities going public with their problems. If one was being uncharitable, one might say this is a growth industry.
- The foundation of support and awareness raising organisations described above.
- Increased awareness of post-traumatic stress disorder amongst Army veterans, especially those who served in Vietnam and the victims of institutional sexual abuse.
- The rise in the popularity of complementary medical therapies, such as reiki which claim to treat mental health issues as well as physical complaints. I haven’t the slightest doubt that reiki is an exemplar of a pseudoscience, but it has, like other CM disciplines, many adherents.
Inevitably, there has been a reaction to the widespread recourse to mental health treatment. Some of this is pejorative and caricature; some of it is abusive. The expression ‘toughen up, princess’, might be humorous – or intended to be – but the widespread use of the term ‘worried well’ worries me, partly because I have been on the receiving end of it. Such a flexible word though. It can mean that if you were really suffering you would be on prescription tablets, not sitting on the couch talking ad nauseum to your counsellor. In other words, indulging yourself. Or it can mean you are not sick at all. Yet within that unpleasant accusation is a clue to a far more intelligent critique of the current day approach to treating mental health.
When I was tutoring in a subject called Body, Mind and Medicine at the University of Melbourne, an easy way to talk about difficulties in the classification of mental illness was to tell my students that the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the unofficial canon in this field, listed as a phobia, fear of peanut butter sticking to the roof of one’s mouth.[xiii] And sex addiction and a few other items which sounded ridiculous and offered a cheap laugh for the teacher. I apologise here for never checking if these syndromes were actually in the DSM. Possibly, the real crime with the peanut butter phobia was the horrific name given to it – Arachibutyrophobia.
But arguing that medical health is open to over-diagnosis is not just something your know-all cousin comes up with at Christmas. Let us look at two studies, one American, one local. The first is Saving Normal, published in 2013, and written by Allen Frances, immodestly described by his publishers on the cover blurb as ‘one of the world’s most influential psychiatrists’. More significantly, he was chair of the DSM-IV Task Force which means it is time to more fully explain what the DSM is.
The DSM, a product of the American Psychiatric Association, was first published in 1952, and has been revised considerably ever since. Currently, we are in the reign of DSM-5-TR which appeared in 2013, though it has been updated several times since. Widely influential inside and outside the United States, it provides a lexicon of mental disorders with diagnostic criteria intended to assist practitioners and researchers, but its market extends to lawyers, pharmaceutical giants and insurance companies. Given you can access it (via a suitable payment) online, it is useful for self-diagnosis if one cannot be bothered seeing a professional. As could be gleaned from my rude comments about peanut butter phobia, it is comprehensive to the point of madness (weak joke intended). New syndromes appear, old ones – such as homosexuality, mercifully – are deleted.
For Frances, writing very much as an insider, DSM 5 is guilty of turning too many ordinary, that is ‘normal’, aspects of our existence into mental health disorders. He is especially concerned that this suits the interests of the pharmaceutical industry. In his sights are what in 2013 he called ‘the fads of the future’: ‘disruptive mood dysregulation disorder’ (child tantrums), ‘mild neurocognitive disorder’ (getting forgetful as you get older), ‘adult attention-deficit hyperactivity disorder’ (ADHD already being a common diagnosis amongst children). There are others. Frances’ overarching message is the following:
My hope is to simultaneously serve two purposes – first to alert people who don’t need treatment to avoid it, but equally to encourage those who do need treatment to seek it out and stick with it. My critique is only directed against the excesses of psychiatry, not its heart or soul. “Saving normal” and “saving psychiatry” are really two sides of the very same coin. Psychiatry needs to be saved from rushing in where it should fear to tread. Normal needs to be saved from the powerful forces trying to convince us that we are all sick.[xiv]
Useful advice and a criterion based on common sense, especially if one is about to embark on a course of medication. Yet, each of the syndromes with their tongue twisting names requires separate examination rather than universal acceptance or condemnation. All children, unless sedated from birth, will throw tantrums. So that’s normal, but constant tantrums? They bear investigation. Adult ADHD might be described as faddish, but since Frances published his critique many psychologists are convinced that this is a syndrome that has been seriously under-diagnosed.[xv]
In a Quarterly Essay published in 2005, the Australian author Gail Bell had drawn attention to what she calls ‘the medicalisation of our sorrows’, and the subsequent prescription to one million people of anti-depressant drugs. This is a powerfully argued piece, perhaps now requiring some revision, and with some problematic historical statements, but vital reading, nonetheless. She points out what may be called the ontological dimensions of drugs becoming a crutch:
Pharmacotherapy alone, without a retinue of adjuncts like cognitive therapies and lifestyle changes, squeezes out any other definition or understanding of what happiness is. It positions us in the area of bio-reductionism. We are our hormones. We are neurotransmitters. It silences other voices. [xvi]
Bell’s essay appeared eight years before the book by Frances. But the chronological switch was useful because the reference to cognitive therapy and lifestyle changes leads us back to the relatively recent take up of counselling and non-pharmacological approaches to mental health issues, which is where this article started. Yet, as has been mentioned, even the talking therapies have their critics – and one issue is that the treatment may be extended unnecessarily. New York psychotherapist, and ‘executive coach’, Jonathan Alpert, raised this point in 2012 and has stuck to it ever since. Ignoring the glibness of a successful spruiker, the following is worth considering:
More and more people are seeking mental health care these days, according to recent news reports – but that doesn’t always mean they’re getting the help they need.
In fact, according to one psychotherapist, some patients actually suffer from too much therapy . . .
“Therapy can – and should – focus on goals and outcomes, and people should be able to graduate from it”, he said.[xvii]
People should be able to graduate from this article too, so let us get to its conclusion. There is no sign that the demand for psychological services in this country is going to recede or peak in the near future. Living in a Victorian regional centre, I can assure you that when ‘counsellors across Australia say they fear their experience and abilities are being wasted, as regional and rural communities continue to struggle with access to mental health services’, they are not exaggerating. [xviii] In Ballarat currently, it takes six months to get your first appointment with a psychiatrist unless you are so ill you can access emergency at the hospital or are compulsorily confined. This genuine issue – the shortage of most specialist health cities outside the capitals – is worth an article in its own right. Other suggested causes of mental distress are far more problematic, such as the outbreak of war in Ukraine where an article in the Age stated that it was ‘hard not to be affected by the news coming out of Ukraine right now . . . as images have poured in of bombings, wrecked buildings, wounded citizens and displaced families fleeing for safety’. Despite our remoteness from this conflict, ‘it’s brought mentally closer; it is claimed, ‘by our access to constant news updates and our shaken sense of safety as a result of the pandemic’. Conditions we can be affected by include distress, anxiety, heartbreak and vicarious trauma.[xix] At first reading, one might scoff but what of Ukrainians in Australia – or Russians – or those who have previously suffered trauma?
My closing statement is that we undoubtedly live in an age where many more people seek help for mental health problems than was the case when I was a young adult. Yes, time poor general practitioners may prescribe too many anti-depressants after a relatively brief consultation. Yes, if you are educated and middle-class you are more likely to access mental health services than those who do not share your educational or financial advantages. That does not mean you are worried well; it means the poor are missing out. Yes, some DSM classifications look a little tenuous. But – there is always one at this stage – recourse to psychotherapy is not just some modern aberration like Twitter or TikTok, and people were not necessarily tougher in the good old days. They often suffered in a silence that ruined their lives and those of their children. They had little choice. I, however, have been through just about every service or mental health practitioner or rehab program you can name. But I chose those options. That’s not manipulation, that’s agency.
And Cowper? He found Christ in those shades, but choice of therapy was more limited in 18th century England. And he survived.
[i] Evelyn Manfield, ‘Psychologists struggle to meet demand amid coronavirus pandemic as waitlists blow out’, ABC News, 3 September 2020, https://www.abc.net.au/news/2020-09-03/psychologist-report-huge-demand-surge-amid-pandemic/12622836, accessed 11 December 2021.
[ii] Australian Institute of Health and Welfare (2022), Mental Health Services in Australia, AIHW, Australian Government, https://www.aihw.gov.au/reprts/metal-health-services/mental-health-services-in-australia/reports-content/medicare-srvices, accessed 24 February 2022.
[iii] Melissa Iaria, ‘Sad details emerge of AFL champion Danny Frawley’s final months’, News.com.au, 23 February 2021, https://www.news.com.au/sport/afl/call-for-afl-players-to-donate-brains-after-danny-frawleys-tragic-death/news-story/a7b7fc7e1356914cd7862dfe48e741f5, accessed 13 December 2021.
[iv] ‘Tender: Roia Atmar’s story of abuse, survival and advocacy’, Guardian Australia, 13 December 2021, https://www.theguardiancom/australia-news/audio/2021/13/tender-roia-atmars-story-of-abuse-survival-and-advocacy, accessed 13 December 2021.
[v] Better Health Channel, ‘Counsellors’, https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/counsellors, accessed 15 December 2021.
[vi] Healthdirect, ‘Psychiatrists and psychologists’, https://www.healthdirect.gov.au/psychiatrists-and-psychologists, accessed 15 December 2021; Healthdirect, ‘Counsellors and counselling’, https://www.healthdirect.gov.au/counsellors-and-counselling, accessed 15 December 2021.
[vii] For early reviews of the mental health strategy see Australian Government, Department of Health (2001), First National Mental Health Plan, https://www1.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-i-midrev2-toc, accessed 24 February 2022. Australian Government, Department of Health (2009), Progress of mental health system reform in Australia, https://www1.health.gov.au/internet/publications/publishingnsf/Content/mental-pubs-f-plan09-toc, accessed 24 February 2022.
[viii] Chlorpromazine is better known under two of its brand names, Largactil and Thorazine.
[ix] It would be impossible to fully appreciate popular culture of the 1960s and 1970s without knowing what Valium was. Mother’s Little Helper was a song released by the Rolling Stones in 1966. Check out Lou Reed’s Walk on the Wild Side as well.
[x] William Bynum, The History of Medicine: A Very Short Introduction, Oxford University Press, Oxford, 2008, p.150.
[xi] Lila P. Vrklevski, Kathy Eljiz, and David Greenfield, ‘The Evolution and Devolution of Mental Health Services in Australia’, Inquiries, 2017, Vol. 9, No. 10, http:/www.inquiriesjournal.com/articles/1654/2/the-evolution-and-devolution-of-mental-health-services-in-australia#header7page2, accessed 11 December 2021.
[xii] MensLine Australia, ‘Men’s mental health common challenges’, https://mensline.org.au/mens-mental-health/mens-mental-health-common-challenges/, accessed 15 December 2021.
[xiii] Given that such a fear derives from an apprehension of choking or gagging, and peanut allergy can be lethal, why the sarcasm?
[xiv] Allen Frances, Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma and the Medicalisation of Ordinary Life, William Morrow, New York, 2013, p. xx.
[xv] Again, if readers are interested, I can provide sources and further information on this issue.
[xvi] Gail Bell, ‘The Worried Well: The Depression Epidemic and the Medicalisation of our Sorrows’, Quarterly Essays 18 (2005), Schwartz Publishing, Melbourne. I have not provided page numbers in this endnote, as in the downloading of my pdf version of the essay the pagination imploded.
[xvii] Mark Abadi, ‘A psychotherapist was flooded with hate mail in 2012 when he said people don’t need years of therapy to get better, and 7 years later, he still hasn’t changed his mind’, Business Insider Australia, 8 January 2019, https://www.businessinsider.com.au/therapy-long-term-jonathan-alpert-be-fearless-2019, accessed 15 December 2021.
[xviii] Rosanne Maloney, ‘Counsellors call for urgent Medicare subsidies to tackle regional and rural mental health crisis’, ABC News, 13 December 2021, https://www.abc.net.au/news/2021-12-13/counsellors-call-for-medicare-subsidies/100689008, accessed 16 December 2021.
[xix] Sophie Aubrey, ‘If you’re distressed about the news in Ukraine, follow these steps’, Age, https://theage.com.au/lifestyle/health-and-wellness/if-you-re-distressed-about-the-news-in-ukraine-follow-thse-steps-20220225-p59zmr.html, accessed 26 February 2022.