The effect of risk-based mental health law on access to mental health service

Abstract

The escalating personal, social and economic costs of poor access to effective mental health services in Australia now demands 'root-and-branch' re-evaluation of Australian mental health policy, and the structure of the public mental health system - including one of its central pinions, mental health law. There is continuing debate about the clinical, ethical and rights-based rationale for the long-standing model of risk-based mental health law. To date, this has not included the examination of its effectiveness as an instrument of policy. This thesis adopts a regulatory governance perspective overall, to examine the effect of the risk-based model of mental health law on one of its principal express purposes - facilitating access to mental health treatment. The question is addressed in the light of competing perspectives in the literature. These include the dominant discourse, as represented in the law itself, that risk criteria in the law facilitates access to mental health services. They include, also, arguments favouring the hypothesis that risk-based mental health law inhibits access to effective mental health service. The thesis describes the development and application of a novel, mixed-model, social policy analysis framework. It integrates a network governance sub-study and a realist governmentality sub-study, with additional formal scoping and synthesis phases. The literature-based network governance sub-study engages a modified critical interpretive synthesis method. The realist governmentality sub-study combines discourse analysis and ethnographic fieldwork, entailing semi-structured, recorded and transcribed interviews with 28 public psychiatrists in five Australian mental health jurisdictions, in a genealogical analytic. The study found that minimising costs and criticism in the electorate were much higher-priority concerns for the state than facilitating access to service. The study revealed significant evidence of governmental strategies to regulate the action of public psychiatrists to support this order of concerns. There was evidence of both compliant and resistant responses by psychiatrists to these strategies. Both types of responses were found to engage mental health law formally - in practice and for purposes as intended by the legislature - but also informally, for other purposes, and with 'creative' interpretation. It was found that mental health law is formally engaged, in practice, to 'responsibilise' public psychiatrists to provide risk-focussed usual care. It is used informally to enforce informal triage practices, especially a range of gate-keeping mechanisms; to support blame and accountability mechanisms leveraged against psychiatrists; and for the medico-legal protection of the state and psychiatrists. Access-negative effects to which these practices contribute include: denial or discontinuance of needed public psychiatric care; non-provision of traditional, holistic, individualised, effective psychiatric therapy; waste of psychiatric time and expertise; and high-levels of despair amongst psychiatrists. The results support the discourse that the risk-based model of mental health law prevailing in many Western jurisdictions - including in New South Wales, Victoria and the Australian Capital Territory - does not 'work' in relation to its object to facilitate access. The central and growing problem of mental illness in the Australian community will likely worsen if it remains in the care of a public mental health service system built around this non-performing regulatory technology.