Promotion, prevention and early intervention
8.1
As discussed in Chapter 7, while the sector does not know everything about mental health, it does know a fair bit about keeping people well. What is known is that the social, economic, cultural and environmental conditions in which a person lives contribute to their mental health, their management of mental illness and recovery from suicide risk. Any effective mental health and suicide prevention system must provide the broader psychosocial supports, beyond clinical care, that are necessary to assist a person’s recovery from mental illness.
8.2
Likewise, interventions to address mental health and prevent suicide cannot be purely reactive. There must be a strong focus on mental health promotion, wellbeing and prevention.
8.3
This chapter discusses first the social determinants of health and the roles of psychosocial supports in assisting people recover from mental illness. It then examines health promotion approaches that aim to provide people with the skills and resilience to support their own mental health. These may also be referred to as wellbeing approaches. The chapter closes by discussing culturally informed practice.
8.4
A key insight from submissions and evidence to the inquiry is that the treatment of mental illness and suicide prevention and aftercare must be holistic. Treatment cannot solely focus on immediate clinical needs absent consideration of broader psychosocial factors; it must be proactive to build resilience and maintain wellbeing in the population, from a young age.
Social determinants of mental health and suicide
8.5
When considering mental health interventions, the Australian Medical Association (AMA) urged ‘respect for the social determinants of mental health’—a person’s health and capacity to access services is shaped by the social, economic, cultural and environmental conditions in which they live.
8.6
Similar views were shared by other stakeholders:
Referring to Maslow’s hierarchy of needs, SANE Australia noted that these are the types of things that ‘sit around and greatly influence someone’s ability to cope and even engage in mental health treatment…’
The National Mental Health Consumer and Carer Forum noted the importance of meaningful employment, education, income, housing, and physical and psychological security.
8.7
StandBy drew attention to research, which highlighted that social determinants are particularly relevant to preventing suicide. The ‘situational distress paradigm’ developed by researchers at the University of Western Sydney challenged the conflation of mental illness and suicide by examining suicide prevention in relation to a range of stressful but common life events, not through the lens of mental illness.
8.8
Suicide Prevention Australia concurred:
… fewer than half the people who die by suicide have got a mental health issue. It's the accumulation of the social determinants that often leads a person to suicidal distress. It's things such as housing, permanent employment and ensuring that they have sufficient funds to either pay for rent or put food on the table et cetera …
8.9
The real causes of suicide, according to the Queensland Aboriginal and Islander Health Council, often sit outside of the health space:
If people feel they've got a safe home, they've got a job, they've got meaning in life, they have cultural identity and community identity, they are more likely to actually look after themselves and not have dark thoughts enter their heads or have thoughts around committing suicide.
8.10
Given the relevance of these broad contextual factors to mental health and suicide prevention, AMA stated:
… we are challenged by longer-term social and cultural determinants of mental health that must be addressed by preventative policy, including education, health literacy, economic stability, employment, disability, age, cultural determinants, climate change, sexual identity and geographic location. The list is very long, but all these factors are critically important if we're going to make a lasting difference to mental health and wellbeing.
8.11
Reaffirming the need for any response to take into account social determinants of mental health, AMA noted ‘there are no simple fixes … this stuff’s all linked up, and the impacts of making a mistake in one area are felt in another area’. Significant investments, then, are required across a range of sectors not commonly associated with health.
8.12
The Queensland Mental Health Commissioner called for a whole-of-government and cross-sector focus, that goes beyond health:
Some of our greatest potential for positive impact is building mental health and wellbeing in the settings of everyday life—that is, where people live, where they work, where they learn and where they play.
Treatment and recovery from mental illness
8.13
The Committee heard from the Australian Patients Association that hospitals are not appropriate mental health interventions and called for consumer-led and co-designed models that focus more on addressing the underlying causes of mental health.
8.14
In much the same way social, economic, cultural and environmental conditions contribute to a person’s mental health and wellbeing, they also influence recovery from mental illness. Witnesses to the inquiry told the Committee an expansion of the psychosocial supports for people experiencing mental illness is urgently required.
8.15
The Productivity Commission Inquiry Report on Mental Health (Productivity Commission Report) defined psychosocial supports as those that address ‘a person’s emotional, social, mental and spiritual needs [and include] a range of services to help a person manage daily activities, rebuild and maintain connections, build social skills, participate in education and employment’.
8.16
The Productivity Commission Report found that to create a person-centred mental health system, reforms would be required to ensure effective services support recovery in the community:
Housing, employment services and services that help a person engage with and integrate back into the community, can be as, or more, important than healthcare in supporting a person’s recovery.
8.17
Addressing the social determinants of health as part of a mental health treatment plan may require investments in accessible housing, for instance. An example was provided by the Australian Rural Health Education Network:
I have a client at the moment that has very significant health issues and mental health issues that are related to COVID and bushfires—a very complicated client that needs cross-sectional support. Part of her presentation is the housing crisis that we've now got in Australia, particularly for the lower-income people who are faced with this idea of being homeless for the first time in their lives. You're looking at a 62-year-old woman who, for the first time in her life, might actually become homeless. So the mental health work I am doing with her has absolutely no impact if I'm not also working on housing and working on social support.
8.18
The Royal Australian College of General Practitioners suggested general practitioners (GPs) get good results in treating mental illness because they operate through a ‘biopsychosocial’ model that offers people social or psychological interventions. Sometimes referred to as ‘social prescribing’, GPs may assist patients to obtain pensions or National Disability Insurance Scheme (NDIS) support, or help with WorkCover or employment issues.
8.19
Interventions like physiotherapy, nutrition and exercise, when part of collaborative and multidisciplinary care, have been shown to assist in the treatment of mental illness, as has financial counselling. The Salvation Army told the Committee:
From what we are seeing, we've got figures from our financial counselling where people come in with a very high mental illness score and then working through and having someone who sits with them and assists them to work through their financial situation—someone who just helps them navigate the system—leads to incredible increases in their mental health.
8.20
This type of approach is also described as a ‘whole-of-person’ approach. As a recovery-based approach, psychosocial services:
… keep people facing mental health challenges connected to their life opportunities, their capabilities, their family, their friends, their community, their education and their work. These factors play a critical role in building longer-term resilience, reducing future harm, reducing distress and reducing risk.
8.21
The Committee heard family and friends are fundamental to the recovery journey of people with mental ill health and should be included, where appropriate, and supported in their caring roles.
8.22
Psychosocial supports are often juxtaposed with clinical interventions. While witnesses to the inquiry acknowledged the role of both in addressing mental illness and suicide prevention, some perceived an emphasis on a medicalised model at the expense of community-based supports and services. The Australian Association of Social Workers called for greater funding and focus on prevention and early intervention.
8.23
Whilst acknowledging the need for psychosocial supports, AMA emphasised the importance and value of ‘actual medical treatment’ for ongoing long-term and recurrent mental illness. AMA also supported the need for a diverse mental health system, which is available regardless of geographical location.
8.24
Accompanying calls for an expansion of mental health and suicide interventions that recognise the social determinants of health and the psychosocial supports required by people to recover from mental illness were suggestions for reform to the Medicare Benefits Schedule (MBS). Suggestions provided in evidence to the Committee included covering assistance for carers under the MBS; reforming the MBS to incentivise collaboration; providing for permanent telehealth MBS items; expanding access to psychotherapy and counselling under the MBS; broadening MBS rebatable sessions with psychologists to include prevention and early intervention; increasing the number of MBS sessions available for psychology consultations; providing MBS subsidised access to gender reaffirming surgical interventions; and including Accredited Practising Dietitians in the MBS. Further discussion on the MBS and mental health is included in Chapter 6.
8.25
Witnesses to the inquiry also called for more general reforms to funding for psychosocial support. Where funding is available, yourtown suggested the funding models themselves may militate against individually tailored psychosocial supports:
Because we have our own flexible funding because, as I mentioned earlier, we generate a significant proportion of our own income through the art unions, we respond to needs. So we look at the needs of our individual clients, and we design services to wrap around what their individual needs are. Unlike a lot of other organisations, who are fully dependent on government funding, we are not constrained by very granular funding agreement clauses.
Committee comment
8.26
Evidence to the inquiry suggests clinical interventions, in the absence of broader measures to address social determinants of health, cannot resolve growing mental health concerns in Australia. As a consequence, the Committee is of the view the sixth National Mental Health and Suicide Prevention Plan must address the social determinants of mental health.
8.27
As a matter of necessity, the plan must provide for psychosocial supports to be expanded and funded, outside the NDIS. If it is acknowledged that a range of supports are required to assist in the recovery from mental illness, then consideration must be given to expanding not only direct funding, but the MBS itself.
8.28
Furthermore, serious consideration has to be given to expanding affordable housing and supported housing services as was highlighted by the Productivity Commission and the Royal Commission into Victoria’s Mental Health System in their respective reports. Stating the extent of investments in affordable housing is not a solution to the problem. The funding that is currently committed in this area is demonstrably insufficient to meet current demand.
8.29
A failure to acknowledge the social determinants of health and to provide adequate funding for psychosocial supports means the mental health and suicide prevention system operates as a palliative. If adequate funding is not made available, then Australia will not achieve the outcomes imagined in recent reports.
8.30
The Committee recommends that the Australian Government ensure the sixth National Mental Health and Suicide Prevention Plan acknowledges and addresses the social determinants of health and psychosocial supports needed in the treatment of mental illness and suicide prevention.
Mental health promotion and wellbeing
8.31
Mental health promotion approaches are generally described as taking a holistic, life course approach to equipping people with the skills to ‘navigate life’s challenges’. Mental health promotion approaches do not mean people will not experience mental illness or rule out the need for clinical interventions, rather they look at building resilience in individuals and communities and ensuring access to services as and when required.
8.32
The Western Australian Association for Mental Health explained the substance of mental health promotion approaches and how they interface with clinical interventions:
… people have had the chance to learn the skills and live in environments and societies that support their mental health up until that crisis point. Then, if that crisis point does arise, that there are services or options available to people who don't necessarily rely entirely on acute and hospital based services, so that there is a range of support and a range of things people can call on in their time of need that don't all rely on having to go to hospital or having to present to an ED [emergency department].
8.33
Some are of the view this type of prevention approach can be overlooked in the mental health field—Prevention United estimated only around one percent of federal expenditure in mental health is on wellbeing and prevention, the remaining 99 per cent is directed to mental healthcare supports and service delivery once someone is experiencing mental ill health.
8.34
Jean Hailes advocated for building up resilience in the entire community, including investing in campaigns to identify needs, rather than just focusing on more psychiatrists and psychologists.
8.35
The Prevention Coalition in Mental Health argued that there has been ‘little emphasis on promotion and prevention, and instead we wait until after people become unwell or are in crisis before we respond’. The Coalition called for ‘greater investment in the promotion of mental wellbeing and the primary prevention of mental health conditions’:
… mental health conditions are not inevitable and there is good scientific evidence to show that we can prevent, or at least substantially delay the onset of many common disorders through evidence-based programs and public policy initiatives that influence the underlying risk and protective factors for these conditions.
8.36
Prevention United contended that this means taking action earlier, with leadership, planning and investment:
We talk to people a lot about mental ill health, recognising the signs and symptoms when someone is struggling to cope, depressed, anxious and suicidal, and we encourage them to seek health. But it always starts at that point of the mental health continuum. It starts at when people are already not travelling well. Then we say, 'See your GP or your psychologist.' That's important but what are we telling them about how to stay well, how to cope with stress, how to manage life's challenges? That's where the mental health promotion conversation needs to be added to the mix, the focus on wellbeing, prevention.
8.37
Beyond Blue called for creating a whole-of-government approach that positions mental health and suicide prevention as everyone’s responsibility.
8.38
Witnesses generally supported mental health promotion that builds resilience and wellbeing and encourages people to reach out for support. Mental health promotion initiatives and links to early intervention can often be implemented in schools and workplaces.
8.39
In addition to wellbeing initiatives seeking to build resilience and encourage early help-seeking behaviours for mental health conditions, they may also focus on encouraging and educating ‘help givers’—friends, family, teachers, supervisors and managers.
8.40
This type of approach has the potential to expand the mental health safety net across communities. An example of the close links between promotion, prevention and early intervention is mental health first aid training, which in addition to educating people on what to look for in others, promotes understanding of mental health in a range of settings.
8.41
Mental Health First Aid International (MHFA) called for the government to commit to 10 per cent of the Australian population being trained in mental health first aid. The organisation suggested this was a practical and tangible approach to mobilising community action at scale and complemented mental healthcare pathways.
Social connectedness and loneliness
8.42
While a number of issues may be addressed through wellbeing initiatives, a key aspect of wellbeing raised during the inquiry was social connectedness—described as a fundamental requirement for human wellbeing. As noted in Chapter 2, the pandemic has magnified social and economic vulnerabilities, which in turn have increased loneliness and social isolation.
8.43
Social connectedness is particularly important as communities live with the COVID-19 pandemic. Ordinarily, at any given time, the Committee was told the estimated prevalence of problematic levels of loneliness is around 5 million Australians.
8.44
There appeared to be very little disagreement with the sentiment shared by headspace that ‘there’s no more important time than now for young people to feel connected in an in-person sense’. While headspace and Dr Kristy Goodwin noted that there were plenty of online opportunities for engagement, this cannot replicate or replace in-person connections.
8.45
As with other mental health interventions, the Committee heard promoting social connectedness and addressing loneliness requires education of community practitioners to assess, monitor and redirect people to appropriate services, and of communities themselves.
8.46
Necessary first steps, according to Interrelate, is awareness, destigmatisation, and normalisation. Subsequent steps, however, are less clear. While it is known that a number of factors reduce loneliness and increase social connectedness, Interrelate explained there was not a single solution:
As with any complex, wicked social problem, we need all target groups and stakeholders working towards solutions. So we need to engage with business, with the community, with education, with the for-purpose sector. We need to engage with the community. We need to co-design solutions. It's really important as well that any solutions need to be co-designed.
8.47
Like all other interventions, funding has an influence on outcomes. The Committee was told any decision as to funding for mental health and suicide prevention interventions requires a trade-off between reactive responses to problems as they present themselves and investment in long-term change. The Healthy North Coast contended that social connectedness is one area where there is insufficient long-term investment:
Out of all the interventions, social connectedness has been demonstrated to have the largest impact on suicide rates over time. It is a matter of balancing the investment. Obviously, if we had unlimited resources we would invest in everything all the time, but it is a challenge to recognise that we need to invest now but also not forget that we've got to invest to actually change the dial.
Promoting wellbeing in the workplace
8.48
The Committee heard workplace responses to mental health and suicide prevention have a role in alleviating pressure on frontline health systems. While this type of approach is separate from the health system, it is also complementary. There is now greater recognition ‘peer based early intervention case management models can dispense with the need for professional gatekeepers’ and thereby help ease the burden on the health system.
8.49
Through its own experience, MATES in Construction stated the issues seen in workplaces ‘are not going to be a surprise to anyone—relationship issues for 38 per cent of those presenting, work related issues are about a quarter, family issues are about a quarter, and financial stress is about one in seven cases’.
8.50
Recognising the ‘fluid factors’ in suicide prevention and the fact a significant number of people may not see a psychologist or other mental health professional, the Australian Association of Psychologists Inc (AAPi) spoke in support of a community focus on suicide prevention, including education in the workforce and in areas where rates of suicide may be higher.
8.51
The Chamber of Minerals and Energy of Western Australia agreed that mental health issues in society require a holistic approach, acknowledging the role employers have to play in addressing mental health as a community issue.
Promoting wellbeing in schools
8.52
The Committee was told the over-representation of young people experiencing mental illness made it necessary to act early in life. The Productivity Commission Report concluded schools should have a clearly defined role in supporting the social and emotional wellbeing of students and recommended making the social and emotional development of school children a national priority.
8.53
Stakeholders suggested a number of reasons it would be appropriate for schools to focus on student wellbeing, including ‘their universality and the proportion of children and young people who attend school’.
8.54
Australian Psychologists and Counsellors in Schools (APACS) told the Committee that although traditionally schools have been focussed on academic learning, over the past 20 years there has been research showing mental health and wellbeing contributes to better academic outcomes and happier children and school communities.
8.55
Furthermore, APACS told the Committee, ‘Most of these children and young people who are having mental health difficulties and sometimes suicidal ideation are in schools’. While acknowledging high schools require more resourcing, APACS stated the focus should be on younger children:
… it's in primary schools where you first see those kids starting to get stressed. They still talk to their parents, their parents will still talk to you, and you can do so much preventative work.
8.56
The Matilda Centre for Research in Mental Health and Substance Use at the University of Sydney also supported a focus on young people and student wellbeing, stating ‘prevention has been demonstrated to give the best evidence of quality-of-life outcomes in their futures’.
8.57
APACS suggested that substantively operationalising a student wellbeing role might require schools to adjust their priorities so measures of wellbeing become as important as National Assessment Program – Literacy and Numeracy (NAPLAN) scores.
8.58
Clear and measurable wellbeing targets were similarly called for by the Productivity Commission in its report when it recommended governments update the National School Reform Agreement to include student wellbeing as an outcome for the education system.
8.59
Witnesses suggested a number of ways schools might address the wellbeing of their students and these are discussed below.
Mental health specialists
8.60
AAPi stated psychologists in schools have the capacity to provide early intervention and counselling support to reduce the need for students to be removed from schools to receive care. Bringing psychological care into schools, AAPi argued, would result in ‘a big improvement in the mental health of our young people’.
8.61
However, according to witnesses, several factors stymie actions in this area. One factor is a shortage of school psychologists which leads to the involvement of people who may not be qualified to provide counselling and psychological support:
Because there aren't enough school psychologists and counsellors, what people have tried to do, realising the need, and in all good faith, is to put other people into the system. You start with school chaplains. School chaplains are not supposed to counsel, but they do.
8.62
To address current shortages, other professionals with less training are being employed, such as wellbeing coordinators and chaplains under the National School Chaplaincy Program. This stop-gap measure, according to APACS, leads to fragmentation.
8.63
Further compounding this problem is the absence of a national standard for mental health professionals in schools. Not all school counsellors are registered psychologists. State education departments decide on the level of training required by school psychologists and counsellors, the tasks they undertake, and how they are allocated to schools. As gaps in the workforce are recognised, education departments may rely on professionals without experience working in school environments. APACS explained:
We've had clinical psychologists sometimes come into a school to look after mental health, even though educational and developmental psychologists are fully trained in psychopathology as well. They come into a school and they work to this model of seeing one client per hour. You can't do that in a school. There is no way that you can pay a full-time person to see six clients a day in a school.
As a school counsellor and as a psychologist, you hit the ground running at eight o'clock in the morning, you don't even draw breath as you're getting out of your car before all of these staff descend on you and kids descend on you. You say, 'Can I just get to my office? I need a drink of water. I just need to put these things down.' You don't get any breaks at all. Hopefully, sometimes you get into the playground so you can at least talk with kids and show them that you're a normal person. You're there until the last person leaves the school and the cleaner kicks you out. Everybody who does this job has overcommitted to work in this space and continues to make their professional development a high priority.
8.64
APACS recommended not only a ratio of one school psychologist or counsellor to 500 students (an increase of 100 per cent on the current rate), but that school psychologists and counsellors be resourced and empowered to assume a leadership role in mental health promotion, prevention and early intervention.
8.65
Noting ‘the paucity of qualified psychologists in Australia’ at the moment, Dr Karen Martin and Dr Emily Berger suggested there is a role for social workers to be integrated into school mental health care teams:
Such implementation would enable psychologists to do the expert mental health care they are trained to do. Social workers are connected with social services and have policy knowledge held by few other trained professionals.
Wellbeing programs
8.66
The Matilda Centre told the Committee schools are an important opportunity to provide evidence-based wellbeing initiatives to prevent the onset of mental health and substance use disorders. Evidence to the inquiry suggested this is something also sought by students who want the skills to recognise their own feelings but also the tools to manage their own mental health and to support their friends.
8.67
Interrelate maintained that teaching children about social supports, empathy and maintaining healthy relationships is critical. Such ‘preventative skills’ and programs promote social interaction, connection and respect.
8.68
Prevention United said concepts of self-care and the psychosocial skills that come from health, clinical and positive psychology can be taught in a positive mental health promotion course. Prevention United stated what is often taught as mental health first aid or mental health literacy ‘is really mental illness literacy … you need to complement that with a similar course that is about how you support or enhance good mental health.
8.69
Nevertheless, the Committee heard education about mental illness is also important. MHFA argued mental health education is an essential part of the overall mix of supports to complement clinical, medical and informal mental health service provision:
There's a lot of awareness around mental health, but there's almost a fear of, 'I don't want to say the wrong thing; I don't want to make it worse, or I'm not going to be equipped to know how to respond if someone says that they're not okay.' That's almost a barrier for people. If they do a course such as mental health first aid, it gives them the skills not only to identify what is going on for people but also to actually practice those conversations and find their own authentic way to have a conversation.
8.70
Mountains Youth Services Team suggested all year 8, 9 and 10 students be trained in teen mental health first aid.
8.71
Whilst emphasising the importance of embedding evidence-based wellbeing programs, the Black Dog Institute noted it is typically left to school principals to determine what should be happening in their schools and ‘as a result there’s a lot of stuff happening in schools which isn’t in line with the evidence base of what should be occurring’. batyr agreed, ‘it is a crowded market in some ways, and schools need to know what’s evidence based’.
8.72
APACS questioned the value of some of these programs, suggesting that even when properly administered, programs to promote resilience, mental health and anti-bullying have been shown to have very small positive-effect sizes, ‘in layman’s terms, they don’t make much difference’. Further, APACS suggested there are many commercial programs that are not supported by any evidence at all. APACS urged instead a focus on the ‘hidden curricula’ which was explained as:
… the way you teach … Teachers have to be taught about being kind, about thinking that this is a child that they are teaching … It's not the subject matter that is the most important to get through, it's taking the teachable moment. What makes resilience is knowing all that background. It's the way we conduct schools that counts, not running little programs like 'You do this and there won't be any of that.' It's not proven; it's not shown. And it won't be shown because it won't work.
8.73
Not all agree with this perspective, arguing there is in fact a strong evidence base for some programs. The Australian Council of State School Organisations (ACSSO) suggested an Australian curriculum that provided guidance to teachers on programs that are beneficial for particular age groups would be helpful.
8.74
Others highlighted the Be You program from Beyond Blue that provides a framework for assessing social and emotional learning programs and mental health programs. It is regarded as a useful tool to assist schools to make informed choices about the programs available without limiting the range of options to meet their particular needs.
Teacher training
8.75
The Committee heard wellbeing programs on their own are not sufficient to address mental health in schools. Several witnesses told the inquiry that greater teacher training is required—training to teach certain programs, and to develop the skills to respond to wellbeing concerns in their students.
8.76
Prevention United supported school-based mental health promotion. However, it cautioned that while there is evidence supporting the capacity of some social and emotional learning programs to boost wellbeing and prevent mental health, this could depend on how they are taught. For some programs, teachers require professional development in particular skill sets, ‘not just generic professional development in mental health’.
8.77
A focus on training was also raised by University of Wollongong’s Professor Brin Grenyer, who suggested teachers are also looking for evidence-based responses to signs of emotional disorders in children. In addition to global interventions that focus on giving all children a level of mental health and wellbeing and wellness, Professor Grenyer said there is a need for a workforce strategy to give school counsellors, psychologists and members of the welfare team the skills and strategies to address these issues directly.
8.78
batyr supported this, and noted helping teachers develop the skills to deliver wellbeing programs is only part of the task. batyr called for the training of teachers as gatekeepers. It argued teachers are under enormous pressure to support young people—‘they play incredibly important support roles but they’re not necessarily equipped to do that’. batyr emphasised that when young people do reach out early, they must get the support they need to prevent worsening mental health outcomes.
8.79
Evidence from ACSSO supported this general sentiment. It stated a key set of tools teachers need includes trauma informed practice, student wellbeing, and resilience. These should be implemented in teacher education. Smiling Mind agreed, teachers need training and support to implement programs that take a social and emotional learning framework approach within the context of the curriculum.
8.80
Wesley Mission confirmed ‘a multilayered approach is really needed. It’s not just targeting students; it’s also, working with staff, working with parents, working with the whole community’.
Multiple contact points for students
8.81
ACSSO reflected that while there was no consistent route that children might take to speak to an appropriate person within a school, it was important that students were not required to explain themselves to multiple people before they received the support they needed, or required to talk with people with whom they did not feel comfortable. ACSSO suggested an approach that combined consistency and flexibility so:
… children know that they can go directly to the professional in their school or they can go to their classroom teacher, who they feel really comfortable with and already have a good relationship with, but they don't have to follow a strict process of X number of people where they have to lay their soul bare to everybody.
Connecting schools with local services
8.82
The Committee received evidence that there can be a disconnect between schools and their local services. ACSSO said schools ‘aren't particularly good at building relationships with other key people in children's lives, be it the child's family, let alone maybe the child is seeing a psychologist outside of school. Schools still haven't quite broken down that interagency barrier either yet’.
8.83
APACS was of the view school psychologists and counsellors can serve as the critical link between student, family, community, school and external support agencies—if there are sufficient psychologists and counsellors, and if they are sufficiently resourced.
Committee comment
8.84
Mental health promotion approaches, by building resilience over time in the community, have the capacity to move the dial on the incidence of mental illness and suicide in Australia. These approaches both encourage and require the community to recognise it has a role in mental health and suicide prevention.
8.85
Mental health promotion, however, should not be mistaken as a panacea for addressing mental health problems and suicide interventions. Mental health promotion approaches must sit alongside and complement interventions that recognise the social determinants of health and respond with appropriately funded and targeted supports.
8.86
The need for social connectedness is one area brought into sharp focus by the COVID-19 pandemic. The Committee encourages the Australian Government to ensure sufficient long-term investment in measures to increase social connectedness and address loneliness—across the population.
8.87
The Committee is of the view workplaces and schools have an important role to play in promoting wellbeing and building resilience across the community. If successfully implemented, wellbeing interventions have the potential to reduce the incidence of mental health problems and the strain on frontline health systems.
8.88
The importance of wellbeing programs in schools, from a young age, cannot be underestimated. Young people are over-represented in mental health statistics and the Committee agrees with the Productivity Commission Report that schools should have a clearly defined role in supporting the social and emotional wellbeing of students. The Committee is of the view clear and measurable targets for student wellbeing as an outcome should be established and supports the Productivity Commission Report recommendation to this effect.
8.89
However, to effectively take on wellbeing as a responsibility, schools require support and funding. The Committee heard there is a shortage of school psychologists and counsellors which sometimes results in people without appropriate training being called on to provide psychological and counselling support. Students must receive professional and evidence informed psychological support when it is needed from qualified professionals with experience in school environments.
8.90
The Committee supports a ratio of one full-time equivalent school psychologist on-site for 500 students. It also supports school psychologists being empowered to assume a leadership role in schools. Consideration should be given to integrating other qualified mental health professions into the mental health care team, but this must be done on the basis of clearly defined roles and qualification requirements.
8.91
The Committee recommends that the Australian Government work with state and territory governments to:
conduct an independent evaluation on the effectiveness of existing programs that support wellbeing in schools, including the National School Chaplaincy Program, with a focus on the outcomes of children participating
implement an agreement to increase the ratio of school psychologists to a minimum of one full time equivalent on-site for every 500 students across all levels of school.
8.92
If schools are to be made responsible for wellbeing outcomes, they require assistance to sort through the plethora of wellbeing programs. The Committee supports greater guidance being provided to schools on evidence-based and appropriate wellbeing programs through the Australian curriculum, and through the continuation of Beyond Blue’s Be You program.
8.93
The Committee supports teachers being trained to provide wellbeing programs and the inclusion of mental health in teacher education and professional development programs. It is also essential teachers receive training to respond appropriately when students reach out for help. The Committee supports and strongly urges the inclusion of trauma informed practice, student wellbeing, and resilience in teacher education.
8.94
Finally, young people themselves have a role to play. More often than not, the first person a teen will turn to will be a friend. Making sure they have the skills to know how to respond when a peer reaches out for help, or just seem to be out of sorts, is another layer of protection that can be applied.
8.95
The Committee would like to see mental health first aid taught to all young people no later than in the early years of high school.
8.96
The Committee recommends that the Australian Government prioritise the needs of young people by implementing a national prevention and wellbeing strategy through the Australian curriculum, which includes upskilling staff and students.
Culturally informed practice
8.97
Culture is a fundamental aspect of health for many communities, particularly Aboriginal and Torres Strait Islander communities for whom cultural identity is a core component of resilience. The Aboriginal Health and Medical Research Council of NSW (AHMRC) clarified that there is a clear link to improved mental health and social outcomes when there is a strong cultural connection.
8.98
The National Aboriginal Controlled Community Health Organisation (NACCHO) explained that for Aboriginal and Torres Strait Islander peoples, social and emotional wellbeing:
… describes the holistic nature of health, encompassing our social, emotional, physical, spiritual and cultural wellbeing. It recognises our connection to country, community and culture, family and kinship, and spirituality and our ancestors. It recognises that a person's wellbeing is influenced and impacted by past events, traumas and government policy. It is a term that encompasses both mental health and mental illness.
8.99
As such, when considering risk factors for mental health, the Kimberley Aboriginal Law and Cultural Centre advised:
… the risk is not having culture. To build that culture is a preventative. To build culture is your support and it's your protective factor in a person's whole wellbeing. And, if you're Aboriginal, culture is everything and it's in everything that you do.
8.100
This understanding of what mental health means to Aboriginal and Torres Strait Islander peoples, must, according to NACCHO, be understood and acted upon by governments. Absent an understanding of culture, services are unlikely to meet the needs of the community.
8.101
AHMRC described how Aboriginal people overwhelmingly report a lack of cultural competency and safety when engaging in mental health and suicide prevention services. For instance:
… many Aboriginal people find the language of psychiatry alienating and stigmatising and the classification can mask the real health needs of Aboriginal people. This has been a persistent barrier that compounds the impact of intergenerational trauma and institutionalised racism that underscores the experience of every Aboriginal person who enters the Australian health system.
We know that health services, with their predominantly biological paradigm, have paid scant attention to the connection between history, culture and individual health.
8.102
Across culturally and linguistically diverse communities, witnesses to the inquiry spoke of the necessity for cultural competence in the mental health sector. AHMRC defined cultural competencies as knowledge, behaviours and attitudes that impact policies and systems.
8.103
The Centre for Multicultural Youth said every person should be able to ‘walk in and see a professional who is culturally responsive, who has the intercultural awareness of their own values and their own world views’.
8.104
The Multicultural Youth Advocacy Network described the impact of mental health services that are not culturally responsive, particularly for younger people:
I myself have gone to some sessions with mental health professionals and often feel worse afterwards because I have to maybe give emotional labour for myself, explaining my culture, explaining my problems to them, and often reacting to quite inappropriate comments and inappropriate understanding about my issues.
8.105
In addition to developing cultural competence in the mental health workforce, diversifying the workforce was suggested as a way to improve the cultural appropriateness of care. For instance, the Royal Australian and New Zealand College of Psychiatrists described the benefit of employing people from diverse backgrounds:
… people have experience of training in a different system elsewhere—in their country of origin or in another country—it enhances their knowledge and skill level in addressing, dealing with and talking to people who come from different and diverse backgrounds. So, in many ways, they are actually at an advantage to contribute to a multicultural and diverse society in a better way to help them achieve their goals, compared to somebody who hasn't had that experience of working in a different system … They are more adept in many ways to address that issue of multiculturalism and diversity.
8.106
Further discussion on the development of the mental health workforce is included in Chapter 5.
Committee comment
8.107
Culturally informed practice means that rather than solely investing in traditional mental health service interventions; investments may be equally required in language and culture, and to promote healing from intergenerational trauma, racism, and sustained grief.
8.108
The Committee is aware many of the steps to promote wellness and resilience in Aboriginal and Torres Strait Islander communities are set out in the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017-2023. This framework reflects evidence presented during the inquiry that cultures must be strong to support social and emotional wellbeing and mental health.
8.109
The Committee acknowledges the framework is intended to help guide and support Indigenous mental health policy and practice, but notes that absent funding no framework can improve health outcomes.
8.110
The Committee recalls evidence from AHMRC that sufficient funding must be allocated to ensure the adequate implementation of Commonwealth strategies and frameworks. The Committee urges the Australian Government to ensure sufficient funding is provided for the implementation of measures to achieve the outcomes identified in the framework, and for this funding to be provided in a manner that is flexible to meet the needs of communities on the ground.
8.111
More broadly, the Committee emphasises that mental health interventions that do not provide a culturally safe experience for people may cause greater harm or result in people not seeking the support they require. Accordingly, the Committee is of the view there needs to be a common mental health language that is shared across the community, and especially vulnerable groups. This would include increasing people’s understanding of the role of the various professions in the wider mental health workforce.
8.112
In addition, there should be compulsory training of the mental health workforce in the provision of culturally appropriate care. Though the Committee cautions this should not be the sum extent of training for the workforce in cultural competence.
8.113
The Committee recommends that the Department of Health and the National Mental Health Commission develop, define and promote a common mental health language that can be shared across the community, and especially vulnerable groups including Aboriginal and Torres Strait Islander peoples, other culturally and linguistically diverse communities, elderly, youth, and LGBTIQ+ people.
8.114
The Committee recommends that the Australian Government fund the development of training resources for the mental health workforce in the provision of culturally appropriate and sensitive services to Aboriginal and Torres Strait Islander peoples, other culturally and linguistically diverse communities, and LGBTIQ+ and sex and/or gender diverse individuals. Such training should be mandated through Australian Government funding agreements.
8.115
This report has covered a range of issues of relevance to mental health and suicide prevention. It closes with the following simple observation—over and over again throughout the course of this inquiry, the Committee has been reminded that there is a great deal of knowledge about how to build resilience in communities, about the factors that contribute to mental health problems and suicide, and effective and evidence based holistic responses that provide a broad range of psychosocial supports. The Committee is of the view governments should get on with operationalising this knowledge and funding it appropriately.