Mental Health Association of Central AustraliaULindsay Avenue, Alice Springs | PO Box 2326 Alice Springs NT 0871

p: (08) 8950 4600 | f: 08 8952 1574e: info@mhaca.org.au | w; www.mhaca.org.au

MHACA

SUBMISSION TO SENATE STANDING COMMITTEE

ACCESSIBILITY AND QUALITY OF MENTAL HEALTH SERVICES IN RURALAND REMOTE AUSTRALIA

MAY 2018

Dear Senate Standing Committee Members,

Mental Health Association of Central Australia (MHACA) welcomes the opportunity to make this submission to The

Senate Standing Committee in relation to the accessibility and quality of mental health services in rural and remote

communities. Being based in Alice Springs and servicing remote communities across the Northern Territory this is an

issue that concerns us greatly.

ABOUT MHACAEstablished in 1992, MHACA offers psychosocial support services and educational programs aimed at enhancing the

mental health and wellbeing of people living in Central Australia. It is the only specialist psychosocial support

organisation in Central Australia.

We strive to make a difference in the lives of people with a mental illness by supporting participant-d riven mental

health recovery, and assisting communities and organisations to actively improve mental health and well-being

through:

• Individual support to people experiencing mental illness;

• Drop-in centre offering shower and laundry facilities, group activities and peer support;

• Tenancy support for people who are homeless or at risk of homelessness due to mental illness;

• Mental health promotion to reduce stigma and raise community awareness;

• Training in mental health first aid and suicide intervention;

• Advocacy for improved services at local, state and national levels;

• A Territory wide suicide prevention program developed and delivered in conjunction with remote Aboriginal

communities.

MHACA is a member of the Northern Territory Mental Health Coalition and supports both its submission and that of

CMHAtothe Inquiry. Often when people think about mental health services they focus on clinical services, however

it is organisations like ours who are involved in the daily lives of people with mental illness, assisting to establish

meaningful and fulfilling lives in their communities, and helping individuals and their carers to navigate the service

systems. MHACA supports the call for a rural and remote mental health taskforce to address service gaps and build

capacity to deliver quality clinical and community mental health support services to rural and remote locations.

Mental Health Matters

RESPONSE TO TERMS OF REFERENCE

a) The nature and underlying causes of rural and remote Australians accessing mentalhealth services at a much lower rate

As noted in the submission by the NT Mental Health Coalition and Queensland Alliance there is a range of complex,

interrelated factors that impact on the accessibility and quality of mental health services in rural and remote

communities in the Northern Territory, despite a reportedly higher rate of mental ill-health in these communities. At

its most simplistic level the lack of services isa key factor. As identified earlier there are very few psychosocial

support services available in Central Australia outside of the population centres of Alice Springs and Tennant Creek.

MHACA is the only service funded through the Northern Territory Government to provide psychosocial support

services outside of the Top End, and that is for a small home-based support program for people living in Alice

Springs. The Territory has relied on Commonwealth programs, such as the Personal Helpers and Mentors (PHAMS in

Alice Springs, Papunya and Tennant Creek); Day 2 Day Living Program (Alice Springs) and Partners in Recovery (Alice

Springs and Tennant Creek) to be the vehicle for delivery of psychosocial support services. These services are all

quite restricted in terms of their geographical coverage and what they can offer, so there are vast areas of Central

Australia which have no access at all to specialist mental health support.

When talking rural and remote mental health in Central Australia we are really talking about a response to Aboriginal

people with mental health difficulties, as they are the largest proportion of the population and those with the least

resources. We have no Aboriginal Mental Health policy in the NT.

In the past the NT Government supported the development of an Aboriginal Mental Health Workforce attached to

health services, facilitating culturally accessible service delivery, and acting as a key facilitator for access to clinical

mental health services. In the past few years there has been a significant decline in this workforce and a lack of

investment to support its continued development. These clinicians played a critical role in facilitating access to

culturally appropriate service delivery.

Upstream social determinants, such as poverty, unemployment, drug and alcohol use, family violence, chronic

disease and ongoing grief and loss due to higher rates of mortality and imprisonment, are central to the

disproportionately high rates of suicide and psychological distress experienced by Aboriginal and Torres Strait

Islander people in the NT.

Remote communities also experience lack of basic facilities including telecommunications infrastructure and public

transport. Health services generally have a very high turnover of staff which impacts on the relationship building that

may be required to allow people from Indigenous backgrounds to feel comfortable in discussing mental health

issues. Whilst clinical services may visit on a regular basis, this may not be sufficient to allow for more than a clinical

response to a pressing issue or a medication review.

As Michael Marmotsays at the beginning of his book'The Health Gap', we cannot expect people to become well if

we treat them and send them back to the same conditions that gave rise to their ill-health in the first place. These

issues heighten the need for accessible and high quality mental health services, and also for whole-of-government

strategies to address entrenched socio-economic disadvantage.

Mental Health Matters

Service Mix

Central Australian clinical services are delivered by the Central Australian Mental Health Services offering in-patient

beds at Alice Springs Hospital and outpatient clinics in Alice Springs and Tennant Creek. The CAMHS team visit

remote towns on a rotational basis across vast, isolated regions' with varied but minimal services on the ground.

This means there are few options for referral for specialist day to day support and people get what they can from

already over-burdened health and community support agencies.

The Crisis Assessment Team operates in office hours out of Alice Springs but has no outreach capacity, so there is a

reliance on first responders in mental health crises. People are encouraged to present to Emergency Departments if

they have mental health issues, but many Aboriginal people are reluctant to approach hospitals as they see it as a

place people go to die.

Mental health literacy is low and there can be stigma associated with mental difficulties, which also contribute to a

reluctance to access formal services.

Low-intensity prevention and early intervention services are largely unavailable, and child and adolescent services

are particularly under serviced in Central Australia. The RFDS does a great job in offering a primary mental health

care and triage response in remote communities, but again is limited in its capacity to offer recovery focused

support.

There are no forensic youth mental health services located in Central Australia despite the very high rate of young

people with complex mental health and behavioural needs interacting with the justice system. In MHACA's

experience the Social and Emotional Well-being teams located in Aboriginal community controlled mental health

services do not see themselves as having a role for people with severe and enduring mental illness.

There is also very limited or no access to services to support people with complex needs : psychogeriatric support

services, dual intellectual disability/mental health services, no integrated approach to AOD and Mental Health and

no ABI specific services for adults in Central Australia. This is despite the fact that complex presentations are

extremely high. The services people need, and which are available in other jurisdictions, simply do not exist here.

If we had service design and funding allocations tailored to the needs of the population then we would see a much

higher take up of mental health services.

NDIS

At this stage the NDIS is yet to fully roll out in Central Australia, however the Barkly pilot demonstrated that people

with mental health difficulties were significantly disadvantaged in access to the scheme. In part this is because the

mental health services are clinically focused and there are few avenues for people in remote settings to access

impairment assessment. As the focus of the scheme is on functional impairment, individuals who may need support

simply do not have access to the kinds of information that can demonstrate their eligibility. Clinical services and

medical practices have not seen themselves well-placed to provide the information to support the applications and

the person is left high and dry, with no-one believing it is their role to assist the access process.

Mental Health Matters

The price of delivering remote mental health services is not well informed by an understanding of the challenges and

skills required for quality mental health support, or the significant challenges posed in remote and very remote

settings. It is our view that it is very unlikely that NDIS will produce a wider choice of mental health related service

options for people with psychiatric disability in remote settings due to the viability issues associated with service

delivery.

b) The higher rate of suicide in rural and remote Australia

Evidence shows suicide rates in remote and very remote areas occur at a much higher rate than major cities".

Significant work has been done through the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation

Project(ATSISPEP)'" to identify the best approaches to approach suicide prevention within the context of inter-

generational trauma and highly socially and economically disadvantage d communities. They point to the need for

long-term holistic community capacity building approaches embedded and informed by communities themselves.

What we have in the Northern Territory is an uncoordinated set of initiatives through multiple funding bodies, most

of which are short-term in nature, and which are not focused on community engagement and capacity building. It is

inconsistent with all of the evidence to attempt to address suicide without addressing the underpinning factors

which contribute to the levels of despair in remote Australia.

Current approaches do not comprehensively address the significant risk factors for Aboriginal and Torres Strait

Islander peoples, including discrimination based on race or culture, economic and social disadvantage, physical

health, alcohol and substance misuse and interactions with the criminal justice system.

MHACA is in a position to offer a program. Suicide Story (see Appendix), that is informed by the ATSISPEP principles

but it is evident that further resourcing is needed to support the implementation of the community plans, and to

extend and adapt the program so that it can be offered to specific needs groups and across a broader geographical

area.

The commitments in the recent Federal Budget to offer more capacity to address suicidality is obviously not

unwelcome, but in itself is unlikely to make a great difference in the longer-term if it is not part of a comprehensive

community focused strategy. They will also not reach remote communities if they are only based in ED Departments.

c) The nature of the mental health workforce

There are significant challenges in attracting and retaining suitably qualified and skilled staff in regional communities.

There isa complex range of factors that add to the difficulty of retaining suitably trained professionals including cost,

lack of accommodation facilities (e.g. Utopia), short-term employment contracts, uncertain funding arrangements

isolation and adequate support to prevent burnout from the demands of the locations and the nature of the work.

As previously mentioned the lack of commitment to expansion of the Aboriginal Mental Health Workforce is a lost

opportunity to improve accessibility and responsiveness. It is also significant that there has been very limited

commitment to workforce development of the community mental health support workforce or peer workers in the

Northern Territory.

Mental Health Matters

There is a lack of allied health staff in the NT and difficulties for people who wish to complete training to become a

clinical psychologist due to the lack of opportunities for supervised practice. Overtime many of the Aboriginal

Mental Health Worker and Aboriginal Health Worker positions in remote clinics have transitioned to nursing

positions, but unfortunately few of these are experienced in mental health or are in a position to provide clinical

case management. This can result in an over-reliance on pharmacological approaches to the mental health needs of

clients rather than a comprehensive recovery based approach.

d) The challenges of delivering mental health services in the regions

Many people in remote settings do not have English as a first language but there are few resources to support

Aboriginal Health Workers, specialist interpreters or mental health information and resources available in local

languages. Translations are generally in written form despite low levels of literacy. Translation of mental health

information into culturally understandable concepts has been done in some areas of the NT (e.g. through Miwatj in

East Arnhem) but could be extended and promoted more strongly, particularly supporting mental health clinicians to

use these tools in their work.

The costs of service delivery are higher in remote settings. At the most practical level, driving vehicles over rough

roads for extended periods of time adds significantly to wear and tear. Long trips require two staff adding to the

costs. There is also the not unusual experience of delays in service delivery due to safety and cultural reasons which

can impact on what looks like low productivity of staff. Many factors associated with efficient service delivery are

beyond the capacity of providers to control.

e) Attitudes towards mental health services

Nothing further to add other than to note some key factors and the need for greater attention:

• Low mental health literacy

• Stigma reduction

• Culturally appropriate approach and locations

• Community engagement

f) Opportunities that technology presents for improved service delivery

MHACA actively uses Stay Strong, an interactive recovery planning application developed by Menzies School of

Health Research through the Australian Integrated Mental Health Initiative (AIMHI). This approach to planning is

well-received by our client group. There is potential for more effort to be invested in tools which can actively engage

clients with low literacy and where English is not the first language.

Any strategy for greater use of technology would need to address the challenge of providing these services in remote

Aboriginal and Torres Strait Islander communities including cost, reliability and telecommunications infrastructure.

Mental Health Matters

As identified by the Queensland Alliance and the NTMHC, digital therapies may have limited use in remote areas for

practical reasons (access to telecommunications, cost of phones and reliability of connections, literacy) and, though

potentially valuable, may only appeal to a small group

Locally developed, treatment and support options that are culturally and linguistic appropriate, and which build

upon local community capacity, are our preferred approach.

Once again thank you for the opportunity to contribute to the Committee's considerations.

f^A ^ ,Merrilee Cox

CEO

Mental Health Matters

^PESro^J-

Qitrv^

SUICIDE STORY

An irn+'tQtive op tha Wan+Ql h&Ql+h AyyociQtion op CentrQl Aui+vQtiQ

ph (08) 8950 4600 FQK (OS) 8952 1574 ntory@mhQCQ.or9.QU WWVA/. mhQCQ.or9.Quis Lindiay Avenue, Po Box 232& Alice Sprint NT os71 MHACA

Msntal-Health

Association ofCentral Australia

Suicide Story is a suicide prevention program developed specifically with and for remote Aboriginal communities of the Northern

Territory. The program is a three-day skills-based workshop, grounded in the practices of 'both-ways' learning and comprised of

story-telling, group work, short films and animation. Suicide Story creates a safe space for Aboriginal people to share knowledge

and learning about culturally appropriate ways to address suicide awareness and create more resilient, suicide-safer

communities.

Suicide Story was developed by MHACA in partnership with local Aboriginal people of the Northern Territory and maintains an

Aboriginal Advisory Group (SSAAG), to ensure cultural safety and story-telling integrity throughout workshop deliveries. The

program uses cultural practices to guide participants through the process of understanding suicide and reducing stigma so that

participants can effectively identify and respond to the risk signs in their communities.

Suicide Story strengthens the skills, knowledge and confidence of communities to intervene and prevent suicide at the

community level. The program utilizes an integrated approach that allows community members to engage with service

providers, in a culturally safe space, to assess current perspectives and protocols to suicide risk for Aboriginal people in remote

areas. The program content was developed through the teachings and guidance of Aboriginal people in the Northern Territory

and centers on the specificities of Aboriginal protocols and suicide. Given the diversity of today's communities. Suicide Story can

effectively complement other suicide prevention programs tailored towards non-Aboriginal perspectives for a comprehensive

and holistic community approach toward suicide prevention.

The program operates on the platform of cultural safety and is not permitted to deliver in a community unless the request has

been generated by community members, Traditional Owners and Elders. The SSAAG works with the community to determine

how best to focus recruitment (where the greatest need is) and when would be the most appropriate timing for program

delivery. Once all logistics are in place, MHACA staff works to put together an appropriate team of Suicide Story facilitators and

support the community in promoting the workshop prior to delivery. A community follow up (post workshop delivery) is a

critical component of the program to support implementation of the community safety plan.

The main beneficiaries of the program are Aboriginal and non-Aboriginal people living in remote communities of the Northern

Territory who are exposed to suicidal behaviour as part of their work environment or more intimately within their families and

communities. The program encourages the outward sharing of new learning so there is a direct impact within the community of

improved suicide awareness skills. Finally, participants who complete a Suicide Story workshop, leave with the skills to identify

and respond to suicide risk, thus individuals at risk will benefit from the support of informed participants. Feedback from

participants, indicate that the workshops are useful and lives can be saved as a result of their engagement with the program. To

date, Suicide Story has delivered program workshops to over 500 people living throughout the Northern Territory.

' Northern Territory Mental Health Coalition. (2017). Northern Territory Mental Health & Suicide Prevention Service Review.

Retrieved May 7, 2018, from https://www.ntmhc.org.au/mental-health-suicide-Drevention-service-review-2017/

Mental Health Matters

" Australian Institute of Health and Welfare. (2018). Rural and remote health. Retrieved April 30, 2018, from

https://www.aihw.Bov.au/reDorts/rural-health/rural-remote-health/contents/deaths-remoteness

"1 Dudgeon, P. Milroy, J, Calma T. etal Dudgeon, Milroy et (2016) Solutions that Work: What the evidence and our people tell us. University ofWestern Australia

Mental Health Matters