It’s nice that the Federal Government has given a gong to Pat McGorry, but our country’s commitment to psychiatric treatment remains at the level of mere lip service. I read with interest a recent newspaper article reporting on the Federal Government’s scheme for giving subsidies to private psychologists. This program began in 2006, in response to widespread evidence of a ‘crisis’ in mental health. Psychiatric problems constituted a vast percentage of overall health burden in Australia, yet were systematically under-funded (in proportional terms). The then-Howard Government arranged for psychologists operating in private practice to be subject to Medicare rebates for the first time. The aim here was to allow the private system to pick up the slack for an over-burdened public system. These are the results:

MEDICARE spending on psychological therapy will blow out to $1.5 billion by 2011, twice its budget allocation, according to a new analysis.

Despite the huge investment – three times the original five-year estimates when the scheme began in 2006 – the Federal Government has not released any evidence that the consultations are improving mental health…

Long consultations with psychologists grew fastest – by 32 per cent. But they were used disproportionately by city dwellers, with country people only about 60 per cent as likely to attend them.

The analysis also shows patients are being hit by out-of-pocket expenses likely to be prohibitive for those on lower incomes – an average $35 for 50 minutes with a psychologist.

This result is not surprising, and I’d like to touch on two related points to elucidate the origins of this costly failure:

1. The rebate scheme derived from the Howard government’s fetish for lining private pockets with public funds. (This is a fetish he shares with his ALP State counterparts, and Kevin Rudd, ’social democratic’ rhetoric to the contrary notwithstanding). Rather than invest in the necessary infrastructure and staffing to make mental health work in hospitals and the community, the Government has opted for a market solution here – throw money around, and, rather than actually plan anything, let private psychologists (and their ‘clients’) sort it out. This is transparently magical thinking, but it’s standard practice for man economists and bureaucrats today.

Understandably, private psychologists were themselves happy with this scheme. For everybody else, there is little reason for enthusiasm. Firstly, the range of things that private psychologists cannot do makes them totally unsuitable to be the sole clinicians for many of the ‘mentally ill’. A private psychologist cannot prescribe medication, cannot arrange hospital admissions, or crisis assessments. Consequently, all of the shortfalls that existed in the system prior to this rebate have continued. For instance, a hospital in Victoria’s Latrobe Valley failed to meet 80% of its ‘performance targets’. In short, the $1.5 billion in funding didn’t create a single bed for the suicidal and psychotic. This only intensifies the pressure on the poorly-paid, poorly-funded public services. The consequence is that hospital patients wil continue to be churned through the system, CAT (Crisis Assessment Team) services will continue to minimise risk (i.e. “You’re not at immediate risk, you still have one foot standing on the bridge”) etc.

Moreover, as you’d expect from a market-based approach, private psychology services have been skewed to the benefit of wealthy areas. This has been the case for some years, as evidenced by this 2007 report:

IF YOU live around Hawthorn or Kew, finding a psychologist that Medicare will pay for is a breeze. If you live in Reservoir or Footscray, it’s quite a bit harder. And if you’re unlucky enough to live in a country town such as Ararat, you miss out altogether…

Access to Medicare is generally a good thing, but because health practitioners follow the market, Medicare rebates tend to favour those in wealthier, urban areas where health workers congregate, she says.

This is starkly demonstrated by the distribution of Medicare psychologists. Hawthorn and Hawthorn East, with 55 Medicare psychologists, have more than the Northern Territory, with just 22.

Despite the rebate, private consultation still usually has a cost (which varies widely) due to the ‘gap’ between the rebate and a clinician’s fees. Naturally, this has the effect of making the rebate a kind of ‘middle-class welfare’, that favours those with more disposable income. You can test this hypothesis yourself, using Victoria’s Registry of psychologists to search different areas. Affluent Brighton has many more psychologists than Deer Park, for instance, despite each being roughly similar in terms of population size and distance to the CBD. Meanwhile, the Medicare rebate has furthered the proliferation of charlatan McTherapy franchises who see dollar signs where one ought to see suffering (discretion prevents me from naming them). In short, the market behaves here as one would expect. It follows the money, and is completely incapable of solving a complex problem (namely, that of psychiatric care in Australia).

2. The ‘mental health’ industry, independent of funding issues, is rotten to the core. Where it is not geared (privately) for sheer profit, it is driven (publically) for ‘outcomes’ and ‘KPIs’.  This is most evident wherever you find an acronym somewhere in the ‘mental health’ profession, such as the DSM (the dominant basis for psychiatric diagnosis in Australia) or CBT (the dominant form of ‘therapy’). The rise of these acronymic approaches coincides with what one psychiatrist called ‘the dumbing down of mental health expertise’. The ‘client’ of psychology is, in fact, a human, always with a polyvalent history and complex presentation, but in the dominant paradigms of treatment, he or she is reduced to an inert, imbecilic, and readily-quantifiable object, a constant in the equation, if you like, rather than an ‘x’. In practical terms, this means that GPs and psychiatrists prescribe medication as if patients were guinea pigs. Diagnosis by prescription is common practice, with the workings of almost all psychiatric drugs remaining largely a mystery for researchers, despite the grandiose claims of pharmaceutical companies. A whole range of human phenomena, from unhappiness to grief to anxiety are reconstructed as ‘medical disorder’, and therefore rendered, in principle, amenable to drug treatments.

This is compounded by the DSM system, which ought to be an intellectual embarrassment, but which is used as a lingua franca. Then you have the fromagerie of most ‘treatment’ itself – a mix of ’self-help’ techniques, and recipe-book style manuals, all of which provide a one-size-fits-all solution to multiplicitous problems. This is explicitly the case for CBT, whose founder, Aaron Beck, says quite plainly that clinicians ought to ignore a patient’s discourse and manifold array of symptoms in order to effect a ‘problem reduction’. Beck says that this reduction is necessary in order to get the ‘client’ to ‘damp down’  his or her ‘inappropriate emotional reactions’, and reintegrating back into the individualistic production line of alienated, competitive, consumer capitalism.

Needless to say, between markets and their ‘therapeutic’ prescriptions, it’s not surprising that Australia still has a problem with  ’mental health’.