Not Waving, Drowning

On mental health and vulnerability

Sarah Krasnostein

• Publisher: Quarterly Essay
• Year: 2022
• Print ISBN: 9781760643270
• eBook ISBN: 9781743822098
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

How can we mend Australia's broken mental health system?

Mental illness is the great isolator - and the great unifier. Almost half of us will suffer from it at some point in our lives; it affects everybody in one way or another. Yet today Australia's mental health system is under stress and not fit for purpose, and the pandemic is only making things worse. What is to be done?

In this brilliant mix of portraiture and analysis, Sarah Krasnostein tells the stories of three women and their treatment by the state while at their most unwell. What do their experiences tell us about the likelihood of institutional and cultural change? Krasnostein argues that we live in a society that often punishes vulnerability, but shows we have the resources to mend a broken system. But do we have the will to do so, or must the patterns of the past persist into the future?

"In our conception of government, and our willingness to fund it, we are closer to the Nordic countries than to America. However, we're trending towards the latter with a new story of Australia. The moral of this new story is freedom over equality, and one freedom above all - the freedom to be unbothered by others' needs. However, as we continue to saw ourselves off our perch, mental health might be the great unifier that climate change and the pandemic aren't." Sarah Krasnostein, Not Waving, Drowning

This issue also contains correspondence discussing Quarterly Essay 84, The Reckoning, from Gina Rushton & Hannah Ryan, Amber Schultz, Malcolm Knox, Janet Albrechtsen, Kieran Pender, Sara Dowse, Nareen Young, and Jess Hill

NOT WAVING, DROWNING	Mental illness and vulnerability in Australia
	Sarah Krasnostein

“Australians today are a complacent people but our boast of living in a lucky country [is] at times just strident enough to betray that we cannot yet take our material comforts utterly for granted,” wrote J.P. Parkinson, a psychiatrist, forty years ago in the Australian and New Zealand Journal of Psychiatry. He continued, “It would be surprising if we could, considering it is less than two hundred years since our European forebears were regarding a harsh and barren land with horror and despair. John White, principal surgeon of the First Fleet and of the colony of New South Wales, called the country a ‘place so forbidding and so hateful as only to merit execrations and curses – a source of expense to the mother country and of evil and misfortune to its inhabitants.’ Is there any link across perhaps a mere four or five generations between that view and our own?”

Medical histories of settlement have characterised many of the convicts as mentally ill. That would be unsurprising, given the desperation that often led to their crimes, their social isolation and the experience of a death sentence being imposed, then commuted to transportation for life to a place that may as well have been the moon.

Construction of the first purpose-built psychiatric facility in Australia, the Tarban Creek Lunatic Asylum in New South Wales, finished in 1838. Previously, mentally ill people were housed in the town gaol at Parramatta or the female factory or the former convict barracks of the abandoned government farm at Castle Hill, where the first doctors were convicts themselves and untrained attendants were selected for their size and strength.

The state of Victoria’s mental hospitals are older than the state of Victoria. The first purpose-built institution opened in 1848 as a local ward of the Tarban Creek asylum. In 1851, it was renamed Yarra Bend Asylum. Above a sinuous trail where the waters of the Merri Creek meet those of the Yarra River, a bluestone building sat surrounded by a rolling landscape which none of its “inmates” could see. A year passed before reports leaked out. The ensuing parliamentary inquiry heard evidence about patients being sexually and physically abused, filthy facilities, corruption, misappropriation. A new administrator was installed, but conditions continued to deteriorate. There were 251 inmates by 1855; 450 by 1858. A proposal for a new mental hospital in Kew stalled in parliament. So Yarra Bend expanded, new wards built cheaply around the bluestone building, all of it always about to close, no use throwing good money after bad. By 1870, Yarra Bend housed over 1000 people. It operated for another fifty-five years.

“For some time back,” a reader named “Humanitas” wrote to The Argus in 1874, “the bodies of patients who die in the Yarra Bend are buried by ‘contract’; and the contractor is in the habit of conveying the dead bodies to the cemetery in an open spring cart, without a particle of clothing except a small bit of well-worn oil cloth.” The letter continued:

The effluvia from the cart is often something horrible, and to make the matter worse, the contractor is in the habit of driving along this road at the rate of about 10 miles an hour – portions of the road are rough patches of new metal etc.

“Rattle his bones over the stones,

He’s only a looney whom nobody owns.”

Surely this should not be allowed in this Christian land . . .

Not even a century into settlement, there was a glaring gap between values and behaviour – between the offer of asylum and the reality. That gap remains.

*

As the fate of the institutionalised shows, mental illness in the colonies was deeply stigmatised, despite its prevalence. Stigma is a complex social process that excludes or devalues someone on the basis of a particular characteristic. At the time of the Fifth National Mental Health and Suicide Prevention Plan (2017), the stigma attached to mental illness was so prevalent in Australia that most of us had experienced it. The “ever-presence of stigma and discrimination” for those with mental illness – as the federal Select Committee on Mental Health and Suicide Prevention put it in 2021 – was identified as a major barrier to treatment and recovery by both the federal Productivity Commission in 2020 and the Royal Commission into Victoria’s Mental Health System in 2021. Its impacts are compounded for those who experience additional forms of discrimination, such as Aboriginal and Torres Strait Islander peoples and people who identify as LGBTIQ+.

The sociologist Erving Goffman elaborated his theory of stigma in a slim 1963 study, Stigma: Notes on the Management of Spoiled Identity. In his terms, the stigmatised individual is “deeply discredited” by society. They are demoted in their entitlement to social participation, and basic respect, because of a gap between their actual social identity (member of the diverse human race) and their virtual, or assigned, social identity (polluted, spoiled, threat, scapegoat). “We construct . . . an ideology to explain his inferiority and account for the danger he represents,” Goffman explained of the stigmatised individual. “We use specific stigma terms such as cripple, bastard, moron in our daily discourse as a source of metaphor and imagery, typically without giving thought to the original meaning.” Totally crazy, right? A complete psycho. Just madness. Absolutely manic. Schizo. Insane!

In Goffman’s taxonomy, the Normals are the counterpoint to the Stigmatised, policing proximity to society and its benefits. “While the stranger is present before us,” Goffman wrote, “evidence can arise of his possessing an attribute that makes him different from others in the category of persons available for him to be, and of a less desirable kind – in the extreme, a person who is quite thoroughly bad, or dangerous, or weak. He is thus reduced in our minds from a whole and usual person to a tainted discounted one.” This constellation of prejudicial, exclusionary and limiting beliefs manifests in social interactions, in healthcare, in mass media, in apparently neutral rules and procedures, and eventually it can invade the stigmatised person’s inner life. For these reasons, stigma can both cause and exacerbate poor mental health.

No one wrote like Goffman, least of all in mid-century academia; his prose is jaunty and brutal and much of it now reads as outdated. But his incisiveness stands and it comes down to this: at its heart – and it is a hot human heart of animal muscle and accelerating blood – stigma is driven by a need for belonging, but its monstrous tactics ultimately condemn it to be self-defeating. This is because one of the lies Normals tell themselves concerns the universality of vulnerability. No moral charge attaches to something like a cold because of its prevalence and fleeting physical impact. However, despite also being prevalent and treatable, mental illness receives no such leeway. It is instead conflated with weakness, badness, wilfulness, something that only happens to others, something to be feared and, in effect, something to be punished. The question, then, is: why?

*

The mental health system in Australia was failing, even before the pandemic, to provide adequate treatment and support to those who need it. The Victorian Royal Commission comprehensively detailed what this looks like on the ground – and the picture is essentially the same throughout the nation, as demonstrated by the 2020 federal Productivity Commission’s inquiry report on mental health.

Almost half of all Australian adults will experience mental ill-health during their lives, and almost one in five will meet the criteria in a given year. These numbers have likely risen during the pandemic. A 2019 survey carried out by the Australian Education Union indicated that 72 per cent of secondary teachers reported that self-harm had occurred in their schools in the past year. Victoria Police responded to a mental health call-out about every twelve minutes in 2017–18.

In 2018–19, approximately 3189 people presented at the Austin Health emergency department for mental health issues: that equates to at least one person arriving in extreme distress every three hours, continuously, for one year. That’s one metropolitan public hospital. Even before Covid-19 hit, emergency departments were under-resourced to treat an unceasing stream of people who should have had better and earlier options for help.

In 2019–20, there were 3.3 million missing hours. That’s the difference between what was required and the actual hours of community mental health treatment and support delivered by public services. It’s an anaemic measure of unmet demand until you think about how long a minute is when you are desperate for help that does not come, and how one person’s pain passes on to others.

Because of the continuing strength of the stigma attached to mental illness, most Australians do not seek help for symptoms either at all or until they have drastically deteriorated. However, there is no “us” and “them” when it comes to health; mental illness is something anyone can experience, not just Others. By drastically increasing calls to crisis lines and psychiatric admissions to emergency departments, especially for children, the pandemic has proved any basis for the stigma false; but will that be enough to eliminate it?

In this essay, you will encounter three people whose interactions with the state while at their most unwell made them sicker. You will see the stigma that attaches to mental illness, and to anyone constructed as Other, and you will encounter those at the frontlines of how this stigma plays out. Their experiences indicate that despite the rhetoric of care and equality, our public institutions have often operated to penalise vulnerability, and that they have done so with collective consent. But all that might be about to change. In February 2021, the Victorian Royal Commission delivered its final report. In response, the state government committed to act on its recommendations in full. It is the most significant commitment to operationalising change made by an Australian jurisdiction, and the prevailing mood in relation to these promises is optimistic. I’ve spent a year sifting through the evidence before the commissioners and speaking with stakeholders around the nation in an effort to understand what our odds are for deep change.

Because this is a story about the mental health system, it is also a story about housing and hospitals and policing and prisons; classrooms, courtrooms, bedrooms and waiting rooms. It is about what could happen when U too R not OK. It is not about money; it is about where we choose to spend money. It is about things that increase the risk of mental illness: isolation, trauma, stigma, socioeconomic disadvantage and genetics. It is about who gets a fair go and why. It is about siloes, mateship and connective tissue. And while we will talk about recovery and redemption, it is always about history.

IN THE SHADOW OF THE PENAL COLONY

“For too long mental health has been relegated to the shadows within the broader health system,” stated the Victorian Royal Commission’s 2019 interim report. “Many are left to exist on the margins; many feel unbearably alone and defeated when the right services are not available to them; and some take their own lives. There has been some progress, but stigma, discrimination and prejudice remain pervasive influences on the lives of people living with mental illness. As a community, we have struggled to understand mental illness and the varying ways people experience it. Some might say we have lacked the empathy to support people who are struggling.” The sheer prevalence of mental illness indicates that this relegation of mental health “to the shadows” is not only a lack of empathy – it’s also a lack of self-compassion. This in turn indicates it has something to do with fear and shame.

In the analytical psychology of Carl Jung, we have both a conscious persona and a Shadow. Our Shadow contains the hidden parts of ourselves we are taught to revile. In a healthy psyche, these different parts are integrated. But where early life events have had an unaddressed impact, those parts are likely to be unconsciously dissociated, consigned to the depths. And they are more prone to the process of projection, in which our own “faults” – the thing we have no wish to be, as Jung put it – are experienced only as someone else’s failings. Jung saw that if the contents of the Shadow remain unexplored and unintegrated, they will be at the root of problems between individuals and within groups, fuelling prejudice and sparking conflicts.

On the other hand, recognition of the Shadow, as he wrote in Civilisation in Transition, is a connecting force. “A human relationship is not based on differentiation and perfection, for these only emphasize the differences or call forth the exact opposite; it is based rather on imperfection, on what is weak, helpless and in need of support – the very ground and motive for dependence.” We lose much – personally and collectively – by remaining perniciously incurious about what is kept in the darkest, oldest rooms of ourselves.

*

This is not to say that we aren’t moved to attempt to find solutions. Announcing his state’s royal commission in February 2019, Premier Daniel Andrews said that the mental health system was broken. Over the next two years, the commissioners tried to hit a moving target – mapping the landscape of a system that was failing disastrously before the onset of the pandemic. The submissions made clear that people do not know how or where to seek help for mental illness. That they do not, and frequently cannot, access help until they are in extreme distress. That aside from being severely understaffed and under-resourced, services are siloed – incapable of effective communication or cooperation. In the commission’s final report, the phrases “service gap” and “service gaps” appear 104 times. Those gaps, and the knowledge that marginalised people fall through them, are not new; they are mentioned in reports on dysfunction in the mental healthcare systems of every state and territory, and have been for decades. One could drown in the grey literature generated since the first National Mental Health Plan in 1993. What those thousands of pages indicate is that the gaps are not limited to the sterile administrative realm of “services.” The disconnection runs deeper; it appears to be embodied.

The commission’s recommendations “centred on transformational reform.” The goal: “to rebalance the system so that more services will be delivered in community settings, and extend beyond a health response to a more holistic approach to good mental health and wellbeing across the community.” The promised change is monumental, from the official acknowledgment that “mental health is shaped by the social, cultural, economic and physical environments in which people live and is a shared responsibility of society,” to the government’s full commitment to the report’s recommendations at a cost of $3.8 billion. The reforms envisage a mental health and wellbeing system “for all.”

While the vision is new, promises are not. If you are passingly familiar with the history of public inquiries into mental healthcare in Australia, the mission of the latest Victorian royal commission may have evoked a strange déjà vu. “Inquiries are not new in mental health,” Professor Ian Hickie and Sebastian Rosenberg wrote in The Conversation in 2018. “There were 32 separate statutory inquiries into the sector between 2006 and 2012 alone.” They noted that “very few, if any” of the recommendations had been implemented. In 2018, there were “no fewer than 14 inquiries or independent reviews.” This was “business as usual” for the mental health sector, Jennifer Doggett wrote in Inside Story that year. “Despite numerous past inquiries and reviews of various aspects of the mental health system,” the Productivity Commission reported in 2020, “there remains considerable need and scope for reform.” On page 1088 of its report, it noted that the then-current National Mental Health Strategy comprised seven documents totalling over 300 pages. “Insofar as it retains priorities of past plans it risks everything becoming a priority and little being fully accomplished.”

Since 1854, the state has held royal commissions into, among other things: sludge removal (1858), defence (1858), cattle disease (1863), prison discipline (1870), diphtheria (1872), policing (1881, 1905), taxes (1881), butter (1904) and sewerage (1925). There have been more royal commissions concerning vegetables (1885, 1915) than for Indigenous communities (1877). More royal commissions concerning world fairs (1861, 1878, 1889, 1890) than for mental healthcare (1884, 1924, 2021). Royal or otherwise, commissions and public inquiries are a longstanding institutional feature of politics in Australia. They are used to serve a specialised fact-finding and/or advisory function. Another function: they buy time by providing the optics of accountability where an issue has got out of hand or is incapable of a satisfactorily popular fix. A 2011 report by the Victorian Parliamentary Research Service noted it is unclear where royal commissions fit into the accountability mechanisms of the political and legal systems. This might be their appeal.

Since the Royal Commission into Aboriginal Deaths in Custody ended in 1991, there have been over 500 Aboriginal deaths in custody. Since the Royal Commission into Family Violence ended in 2015, intimate partner homicide has remained the most common form of homicide in Australia and most victims are women. Since the Royal Commission into Institutional Responses to Child Sexual Abuse, the processes of the National Redress Scheme have been found to be traumatising for survivors. Since the Royal Commission into Aged Care Quality and Safety, lack of expertise and preparedness in aged-care facilities has resulted in large-scale failures to manage Covid-19, with fatal consequences. Public inquiries are a ritual of Australian society through which the violated moral order is condemned and an idealised image of the collective is restored. However, ...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Not Waving, Drowning
• Correspondence
• Contributors
• Back Cover