Australia and New Zealand Journal of Development Disabilities 1988, Vol. 14, No. I, 9-13.

AN ANALYSIS OF AUSTRALIAN MENTAL

HEALTH SERVICES FOR PEOPLE

WITH MENTAL RETARDATION

T R E V O R R. P A R M E N T E R

Macquarie University, Australia

Undoubtedly, the provision of mental health services is one of the most neglected areas of service delivery to people with mental retardation. Historically the situation in Australia is much the same as developments in countries such as the United States and Canada. The problem of diagnostic overshadowing (Reiss, Levitan, & Szyszko, 1982); the relative lack of interest by psychiatrists; the dearth of training and opportunities for practicum experience in faculties of psychiatry; the concentration of resources in large institutions where the emphasis was upon repressing only the most injurious aberrant behaviours; inadequate or inappropriate training for professional groups such as psychologists and nurses, and an extreme dearth of community-based services for the significant numbers of people with mental retardation who were not institutionalized; are all issues which are canvassed in the contemporary literature and which are relevant to the Australian scene.

1. Who provides the services? The provision of services for mentally retarded people in Australia has generally

followed the trends noted in other Western countries. Those with severe to profound intellectual retardation who could not be managed in the family home were placed in institutional care. In many cases these facilities shared campuses with those for people with psychiatric illness. Not surprising, therefore, is the current trend to disassociate the services for these two groups. In the process, however, the mental health aspects of those with mental retardation have been put further into the background. Somewhat paradoxically when services for both groups were under the direct responsibility of psychiatrists there was little evidence that psychiatry contributed much to the mental health needs of these people.

Direct services for people with severe to profound mental retardation has been the responsibility of state governments. Initially, these services were located within the Departments of Health, which were also responsible for the provision of public health facilities such as hospitals and community health centres. A significant exception was in Western Australia where the services came under the control of Mental Health

I wish to acknowledge the assistance given by a number of people across Australia who responded to my survey of mental health provisions. In particular I am grateful to Dr. Helen Beange, Dr. Helen Maloney and Mary-Ellen Burke for the critical input they provided to this paper.

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10 AUSTRALIAN MENTAL HEALTH SERVICES

Services. Services for those with mild and moderate levels of disability have been shared between state and federal departments of community services, largely through subsidies to nongovernment bodies that conducted schools, vocational and residential programs.

However, more recently significant changes have been taking place in a number of state administrations, partly as a result of the application of the principles of normaliza- tion and the least restrictive environment. For instance, in Western Australia an independent Authority for Intellectually Handicapped Persons has been established with a brief to serve the full range of intellectual disability. In Victoria an Office of Intellectual Disability Services within the ministry of Community Services has been established. In South Australia the Intellectually Disabled Council Inc. was established in 1982 as an outcome of two major South Australian Government reports, the Intellectually Retarded Persons Project Report and the Report of the Committee on Rights of Persons with Handicaps, 1Iol. 2, Intellectual Handicaps. The thrust of these changes in administration and those in the other three states have resulted in a concerted move to provide accommodation for those with severe intellectual disabilities in community residential units.

While there has been a major emphasis upon the accommodation and dally living needs of people with intellectual disabilities, particularly those in the severe to profound range, little attention has been paid to their mental health needs. There is anecdotal evidence emerging that the deinstitutionalization process has in some cases exacerbated mental health problems owing to the stress imposed on residents in the movement from hospital to community-based environments.

As noted in the introduction there are few adequately trained psychiatrists working in this field. Medical personnel who are not sufficiently aware of the mental health needs of people with intellectual disabilities are prone to treat problems in isolation from their total mental health and general health needs. In particular there appears to be an overemphasis upon the control of aggressive symptoms to the detriment of a closer analysis of the basic mental health problem. For instance, there is a serious lack of appreciation by a variety of professionals of the emotional needs of people with mental retardation.

For that significant group of mentally retarded persons whose residential needs are met either in the parental home or in community-living programs conducted by non- government agencies the picture is even bleaker. When mental health problems arise these people generally access the services available in the general community. Only too often, once it is found that the person has been diagnosed as being mentally retarded, he/ she is quickly referred to intellectual disability services. Again, it is usually the aggressive behaviour symptom which is treated rather than any underlying mental health problem.

There are some pockets of good mental health services, however. In Western Australia clinical services are provided by a clinical psychologist who works within the Psychiatric Services division of the Department of HealttL Referrals can be made directly to the psychologist from the Authority for Intellectually Handicapped Persons.

In New South Wales the Head of Community Services for the Developmentally Disabled of the division of Community Health of the Prince Henry and the Prince of Wales Hospitals, is one of the few remaining psychiatrists with direct administration and clinical respons~itities for people with mental retardation.

2. Are the services adequate? As the survey of the Australian scene has indicated that services ranged from being

nonexistent to being minimal at best, one is forced to conclude that services are grossly

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PARMENTER 11

inadequate. The picture is further exacerbated in a continent with a relatively small population of 15 million scattered across vast distances. Admittedly the population is concentrated in a number of large cities situated on the coastal fringes. Nevertheless, in all six states, there are large provincial cities and towns some distance from those minimal services that do exist.

3. Perceived problems of adequate mental health services to people with mental retardation in Australia.

A number of problems exist not all of which are by any means peculiar to the Australian scene. These include the paucity of adequately trained medical personnel, both specialist and generic; a disproportionate amount of resources being spent upon diagnosis in comparison to treatment and a separation between the diagnostic and treat- ment~ services; a lack of coordination between departments providing services to mentally retarded people; a serious shortfall of provisions for those with moderate and mild retardation; and a lack of political urgency to correct obvious problems.

a) Training and provision of medical personnel There is little recognition of the mental health needs of mentally retarded people in

either specialist or generic medical courses in Australia. Obviously the area is considered a low status one for psychiatrists and there is a paucity of content on mental retardation generally in generic medical training.

In specialist programs there is a lack of opportunity for practical field experience. In particular there is little awareness of the need for an interdisciplinary approach, both in terms of the personnel involved and the types of treatments required.

As indicated above there has possibly been too much emphasis in the field upon the use of drugs to control aggressive behaviours to the detriment of a deeper analysis of depressive or psychiatric states. In the generalist area inadequacies in training have become apparent through the inappropriate use of medication by general practitioners.

There has been a lack of attention to preventative care, particularly the issue of the relative social isolation of many people with mental retardation. There is a need for more individual counselling of the retarded people themselves and not just parents which is usually the ease. This is not to deny that a wholistic approach ought to be taken- one that involves the family and any other care providers. A closer analysis of childhood problems may help prevent some of the more intractible problems which emerge at early adulthood.

Somewhat paradoxically there has been a disproportionate amount of resources in most Australian states provided to children's services to the detriment of adults. This position will be further exacerbated by the ageing of the population.

Disappointingly Australia has a very poor record in researching issues related to mental retardation in general, let alone those in the area of mental health. The absence of a small nucleus ofhighty qualified and interested specialist medical personnel has meant that the area has been allowed to stagnate further in the eyes of the general medical profession.

b) An overemphasis upon diagnosis and the separation of diagnosis from treatment In many cases this is apparent in crisis management situations, particularly for people

who have been referred by community agencies. The few specialist services that do exist are often concentrated in the diagnosis of the condition. Subsequent follow-up and treat- ment are then left as the responsibility of personnel who are sometimes perceived as less qualified. One way to correct this situation is the interdisciplinary approach noted above. A greater mutual respect for the roles played by various professionals is also

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12 AUSTRALIAN MENTAL HEALTH SERVICES

required.

c) Lack of coordination between services The degree of coordination between service agencies varies across states. As

indicated earlier some states have made good progress in addressing this issue by the establishment of structures which seek to provide services to mentally handicapped people more effectively and expeditiously. Nevertheless, in some states serious problems arise. For instance in New South Wales the Department of Health assumes responsibility primarily for those with severe to profound retardation, while the Department of Youth and Community Services ostensibly has responsibility for assist- ing those with lesser degrees of handicap at the pre and postschool levels. However, this Department is grossly under-resourced and currently has no permanent psychiatrists to serve even those state wards who are not mentally retarded. In this state, at least, there is a history of a lack of collaboration between departments of health, education and welfare. The establishment of a Premier s coordination unit on disability has gone some way in ameliorating this position, however.

d) A lack of provisions for those with moderate and mild retardation This is a group which appears to fall between the cracks in the services more often.

Possibly one of the reasons is that this group manifests disorders more similar to those found in the general population. Too often their aberrant behaviours lead to mis- diagnosis and they are frequently typed as being simply delinquent. They are often involved in extreme anti-social behaviours and may come under police attention. This group is difficult to distinguish from those of borderline normal intelligence who manifest similar poor survival and social skills.

In 1985 the South Australian government instigated a review of services for behaviourally disordered persons and as a result a Management Assessment Panel for Behaviourally Disordered Persons has been established. The panel however, does not accept referrals from persons suffering from mental illness or mental handicap over whom the Guardianship Board has jurisdiction. This Board has a duty to ensure that a protected person receives any necessary medical or psychiatric treatment.

While the law in this case is quite useful as a necessary condition for treatment there is often a shortfall in it being a sufficient condition owing to inadequacies in resources. A number of other states have adopted guardianship legislation to protect the rights of people with intellectual disabilities, but guardianship will not guarantee appropriate and adequate services.

e) The lack of political awareness to correct problems and deficiencies Despite what may appear as an overly pessimistic picture, there have been some

significant advances in many states to correct past problems. New infra-struetures are being established, such as those in Western Australia, South Australia and Victoria which, if resourced appropriately, will ameliorate some of the problems, particularly those relating to coordination of services.

Various governments have commissioned major reports on the need to deinstit- utionalize services for people with severe and profound mental retardation, but the political commitment to resource the resultant programs adequately is problematic.

There is strong competition within government departments serving people with intellectual disabilities for a share of resources. The fear is that with the push towards community integration (i.e. at the school and residential level) and the argument that more use should be made of generic services, the needs of what is seen as a relatively small population will go unmet.

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PARMENTER 13

4. Future Directions In the light of the comments above a number of recommendations for the future are

obvious. These include more adequate training of specialist and general medical staff, a move to a more effective team approach, the abandoning of the treatment of mental health problems in isolation and a greater emphasis upon preventative measures.

The recent development of a Training Resource Unit by the NSW Department of Health in association with the Unit for Rehabilitation Studies at Macquarie University will hopefully provide a model service. This Unit is designed to assist in the treatment of people with severe mental retardation who also have severe behaviour problems. It came into being as a direct result of the move of mentally retarded people from large hospital facilities to community residential units. There are a significant number whose serious behaviour disorders would prevent their move.

The model followed by the Unit is one of outreach to assist staff in the community residentials. The program is at present largely behavioural in orientation with an emphasis upon the control of antecedent conditions and a commitment to teaching alter- native and more acceptable behaviours. Future developments may include the involve- ment of other specialist services so that it may be able to address the mental health needs of its clients more effectively and to extend its services to a wider range of intellectual disability.

The Australian Association for the Study of Intellectual Disability is currently lobby- ing medical schools attempting to encourage the inclusion of more significent content concerning intellectual disability. Many college-based nurse education courses now contain a major component on developmental disability, ensuring that nurses in general have a better knowledge and understanding of the nursing needs of this group.

It is obvious, however, that the gap in meeting the emotional needs of these people will not be met in the immediate future. Without data on the extent of the problem, it will be impossible to mount an effective campaign to convince the various players of the urgency of the problem.

Reference Reiss, S., Levitan, G.W., & Szyszko, J. (1982). Emotional disturbance and mental

retardation: Diagnostic overshadowing. American Journal of Mental Deficiency, 86, 567-574.

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