Literature Review To Inform a Department of Human Services Project on Responding to People with High and Complex Needs
8 September 2002
Prepared by: Thomson Goodall Associates Pty Ltd 260 Dendy Street East Brighton Vic 3187 Tel: (03) 9592 5868 Fax: (03) 9553 8736 email: [email protected]
Published by the Operations Division Victorian Government Department of Human Services Melbourne Victoria September 2002
Also published on www.dhs.vic.gov.au
(C) Copyright State of Victoria, Department of Human Services 2002 This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright act
1 INTRODUCTION 1
Layout of the Review 2 2 DEFINING AND UNDERSTANDING COMPLEX NEEDS 4
2.1 Introduction 4 2.2 Homelessness Perspectives 5 2.3 Primary Care Perspectives 7 2.4 Disability Perspective 7 2.5 Dual Disability / Dual Disorder Perspective 9 2.6 Personality Disorder Perspectives 10 2.7 Child Protection 15 2.8 Aspergers Syndrome 18 2.9 Criminal Justice Involvement 18 2.10 Concluding Comment 19 3 GOVERNMENT POLICY FRAMEWORKS 20
3.1 Introduction 20 3.2 Deinstitutionalisation 20 3.3 National Policy Context (Australia) 25 3.4 Victoria - Policy and Program Development 26 Mental Health 26 Child and Adolescent Mental Health 27 Disability 27 Juvenile Justice 29 Drug treatment Services 29 The Working Together Strategy 30 Multi Service Client Project 30 Victorian Homelessness Strategy 30 3.5 Selected Policy Contexts of Other States and Territories 31 Western Australia 31 South Australia 31 Australian Capital Territory 32 3.6 United Kingdom 33 4 LEGISLATIVE CONTEXT RELATING TO PEOPLE WITH HIGH AND COMPLEX NEEDS 34
4.1 Introduction 34
4.2 National Context 34 4.3 Victoria 36 Introduction 36 Victorian Government Social Development Committee 36 Community Protection (Violent Offenders) Act 37 Mental Health (Amendment) Act 1996 42 Intellectually Disabled Persons’ Services Act 1986 43 Guardianship and Administration Act 1986 45 Sentencing Act 1991 46 Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 47 Alcoholics and Drug-dependent Persons Act 1968 47 4.4 Selected Legislation in other States and Territories 47 4.5 United Kingdom 49 4.6 Legislation in Other Countries 51 5 SERVICE SYSTEM ISSUES, BARRIERS AND GAPS, RELEVANT TO EFFECTIVE RESPONSES TO PEOPLE WITH COMPLEX NEEDS 53 5.1 Introduction 53 5.2 Service System Gaps and Barriers 54 5.3 Mental Health Services 56 5.4 Forensic Mental Health Services 58 5.5 Disability Services 60 5.6 Child Protection Services 65 5.7 Juvenile Justice 67 5.8 Child and Adolescent Mental Health 68 5.9 Housing and Homelessness 69 5.10 Drug Treatment Services 71 5.11 Gaps and Barriers not Identified by the Literature 72 6 TOWARDS IMPROVED RESPONSES 73
6.1 Introduction 73 6.2 Legislative context 73 6.3 System Based Responses to Improve Services to People with High and Complex Needs 76 6.3.1 Introduction 76 6.3.2 Departmental Program Coordination, and Planning 77 6.3.3 Service System Principles 77
6.3.4 Collaborative Approaches 78 6.3.5 Specialist Responses 80 6.4 Service Principles and Practice Approaches 81 6.4.1 Introduction 81 6.4.2 Service Delivery Principles 81 6.4.3 Practice Approaches 83 6.5 Service Models 84 6.5.1 Introduction 84 6.5.2 Accommodation 85 6.5.3 Outreach 87 6.5.4 Service Delivery Components 87 6.5.5 Functions Within the Service System 89 6.6 Resourcing and Staffing 91 6.6.1 Introduction 91 6.6.2 Resourcing 91 6.6.3 Staffing 92 6.6.4 Stakeholder Participation 92 Concluding Comment 93
Introductory Comments on Methodology This literature review is based on literature identified and procured by the Victorian Department of Human Services (DHS). The literature was sourced through searches of various databases using key words, with documents sourced through the DHS Library. The literature was then supplemented with select documents identified by Thomson Goodall Associates Pty Ltd. It is important to note that the literature sourced by DHS and Thomson Goodall Associates is not exhaustive. Key areas were given priority in order to inform the broader Project objectives. In many instances, however, the review refers to other material, which the reader can source independently if greater detail is required. Thomson Goodall Associates assumes no responsibility for the scope and breadth of the literature review.
1 INTRODUCTION
Over the past few years there have been growing concerns about the difficulty of providing services to a small, but significant group of people in Victoria whose complex needs challenge existing policy and legislative frameworks and service systems. These concerns have been expressed by a range of people and agencies including many within the health, welfare and criminal justice systems. People falling within this group include those children, adolescents and adults who may experience various combinations of mental illness and disorders, intellectual disability, acquired brain injury, physical disability, drug and/or alcohol misuse. The extreme challenging and/or dangerous behaviours amongst this group often result in involvement in juvenile or criminal justice systems. Social isolation, family dysfunction, physical and sexual abuse, homelessness and repeated crises are frequently key features of their life experiences. Several specialist and generalist services are often involved in service provision, including mental health, disability, child protection, juvenile justice, drug treatment, health, education, housing and support programs, aged care, as well as the range of generic community services and resources. Different responses, eligibility criteria and approaches mean that people with high and complex needs are frequently referred from service to service. Without a clear mandate, expertise or service model, services are often ill equipped and unable to effectively assist. Service responses or ‘packages’ are often developed on a case by case basis and at high cost, frequently as a last resort in the midst of one of repeated crises. The Department of Human Services is thus undertaking this project to investigate how strategies can be developed and implemented from a whole Department perspective to respond to people whose needs require a higher level of service planning and provision than the service system currently provides.
While there are many clients with complex needs requiring improved service responses, this project only considers those at the extreme end of the continuum of complexity. The presenting factors that have been defined by DHS as characterising this target population are a combination of all the following: 1 Having multiple and complex presenting problems. Having high and complex needs that are not met or sustained by existing services. Having challenging behaviours that place the individual at high risk to self, service staff and\or the community.
1 Victorian Department of Human Services (2002) Complex Clients Project, Project Brief, Operations Division, DHS, Melbourne.
1 Chronic or episodic behaviours and\or conditions that require long-term service responses. Requiring a service response from two or more DHS programs (or criminal justice) areas. Having a specific need for which there is no current service system response, and\or require a current tailored funding package (usually at high cost). The objectives of the Complex Clients Project are to:
1. Identify, quantify and develop a comprehensive profile of the types of individuals with complex needs (the target group) and the costs/resources associated with service provision to these individuals; 2. Identify strengths and weaknesses of current legislative frameworks that define the provision of services to the target group; 3. Identify strengths and weaknesses of policy frameworks, service responses and any gaps in services; 4. Identify examples of best practice (including anecdotal) and evidence- based research, both locally and internationally, regarding service provision; 5. Develop a service framework and strategic plan for improving responses to the target group taking into account current resource usage, potential resource demands and future workforce requirements; 6. Define appropriate service responses and propose reconfiguration of resource allocations to provide these;
7. Develop recommendations on how service solutions may be supported by legislative change.
There is a vast amount of literature about co-occurring and multiple disorders, or disabilities, particularly where these are accompanied by behaviours and needs which challenge the service system and the communities in which people live. Although broader than the focus of this project, much of this literature is relevant in identifying and understanding some of the key issues and service system challenges specifically associated with effective responses to people deemed to be at the extreme end of the continuum. The literature review that follows presents select findings from policy, legislative, program, administrative and practice developments in a range of disciplines and sectors. These have been selected to inform thinking about appropriate responses for the specific target group for this project. Layout of the Review The Literature Review is set out as follows. Section 2 reviews literature which seeks to define and understand what is meant by ‘complex needs’. A number of perspectives are identified including homelessness, primary care, disability, dual disability, personality disorder and child protection perspectives.
2 In Section 3 government policies in relation to responding to people with high and complex needs are discussed. Deinstitutionalisation is an important policy context noted in the literature. Following a brief reference to the national policy context, literature describing the policy and program frameworks in Victoria is reviewed. Policy contexts in selected other States are summarised. This section concludes with a review of literature examining recent policy developments in the United Kingdom. Section 4 reviews literature addressing legislation pertaining to people with high and complex needs. Much of this section relates to the several Victorian Acts of Parliament covering processes in the health, human services and criminal justice systems. In Section 5 the literature review covers service system issues, barriers and gaps. The material reviewed comprises studies and reviews of human services, health and criminal justice programs which respond to people with high and complex needs. Section 6 presents examples from the literature relating to ways of improving responses. Improved responses are discussed at various levels. At a broader system level, select literature on legislation, and inter departmental collaboration and initiatives, is discussed. At a service delivery level, aspects of good practice are summarised. Organisational factors to support enhanced responses conclude the section.
3 2 DEFINING AND UNDERSTANDING COMPLEX NEEDS
2.1 Introduction
In this section definitions of ‘complex needs’ are examined, seeking to place ‘complexity’ on a continuum of need. Reference is made to theoretical frameworks or professional orientations, and perspectives influencing understanding of complexity of need. A range of terms are used to describe people with ‘complex needs’. Over the last two decades, in Australian and international literature, there has been increasing use of terms such as ‘complex needs’,2 ‘high complex behaviours’,3 ‘multi-service clients’,4 ‘complex clients’ 5 or ‘people whose needs require a high level and complexity of service provision’. 6 The terms appear to be used interchangeably by service providers, funding bodies, government departments and policy makers, and in layperson’s terms refer to people whose needs and behaviours present significant, sometimes (apparently) intractable challenges to all health, human service and criminal justice systems. 7 Based on a literature review, Ecumenical Housing et al note that: High or complex needs are approached from a variety of perspectives including: • the needs of the individual • specific needs associated with the person’s situation (eg. homelessness) • the need for specific services, and/or • the impact of high needs clients on the service system. The report examines theory of need in the literature and concludes that ‘Assessments of individual need . . . typically focus on only those components of a person’s need which are relevant to the provision of a particular service’. 8 Smith argues that definition of need depends on the concepts and practices of those in the ‘need making’ business. It is not need which is assessed in this way, but ‘need-which-can-be-met’. 9 He argues that the categories used by
2 Keene, J. (2001) ‘Clients with Complex Needs. Interprofessional Practice’. Blackwell Science Ltd. UK. 3 Victorian Department of Human Services (2000a) ‘Supporting the needs of Individuals with High Complex Behaviours’, DisAbility Services Division, Melbourne, July 2000. 4 Victorian Department of Human Services (1999a) ‘Managing Clients Initiative. Multi-Service Clients Project’, Community Care Division, Melbourne. 5 Victorian Department of Human Services (2000a) Op. Cit. 6 Ecumenical Housing Inc and Thomson Goodall Associates (1999) ‘Appropriate responses for homeless people whose needs require a high level and complexity of service provision’ A Report for the Department of Family & Community Services, Canberra. 7 Ibid. 8 Ibid. 9 Smith, G. (1980) ‘Social Need: Policy, Practice and Research’, Routledge Kegan & Paul, London.
4 professional practitioners for understanding client need are constructs which derive from a body of accepted rules (diagnoses) or procedures which are frequently different for each discipline, system or orientation. This critique in part explains why one agency may perceive a particular client’s needs as high or complex while another, with different resources and a different model, does not. Discussion of complex needs is found in a range of literature from ‘specialist’ perspectives and systems including mental health, disability, personality disorder, substance abuse, dual disability, criminal justice, child protection and homelessness. Of particular interest is the focus on ‘challenging behaviour’ as an intrinsic aspect of complex needs. Ecumenical Housing Inc et al suggest this is a generally accepted term used to describe behaviour which: • seriously interferes with other clients, staff, routines, families, community agencies or the community at large; • interferes with a person’s ability to learn; • places the person, others or property at risk of injury or damage. 10 There is also considerable interest in behaviour which is both challenging and dangerous. 11 This section describes some of the ways in which different sectors, or disciplines define complex needs.
2.2 Homelessness Perspectives
The literature records a strong relationship between homelessness and mental disorders, 12 and homelessness and substance abuse. 13 In a national study of homelessness and complex needs, including input from the homelessness sector nationally, five behavioural clusters manifested by homeless people with high needs were distilled. 14 The research conceptualises a continuum of need, based on a ‘typology of need amongst homeless people’. The typology defined the Type 1 group as people with multiple non-intensive needs; Type 2 as comprising people with a few intense needs; Type 3 as people with multiple intensive needs which compromise functioning but not ability to meet basics needs; and Type 4 comprising people with multiple intensive needs which compromise ability to meet basic needs and which (often) manifest as one or more of the following:
10 Ecumenical Housing Inc. et al. (1999) Op. Cit. p 45. 11 UK Government British Home Office, HM Prison Service, and Department of Health (2000b) ‘Managing dangerous people with severe personality disorder’, London. 12 Hermann et al. (1988) ‘Homeless people with Severe Mental Disorders in Inner Melbourne’, Council to Homeless Persons; and Hage (1989) ‘People with mental disorder and homeless’, Council to Homeless Persons. 13 Fox, A. (2000) ‘Final Report on the SUMITT Evaluation’, June 2000; Drake, R., Osher, F., Wallach, M. (1991) ‘Homelessness and Dual Diagnosis’, USA; Victorian Department of Human Services (2002b) ‘Victorian Homelessness Strategy: Action Plan and Strategic Framework: Directions for Change’, Community Building Division.; Dickman, S. (1996) ‘Closing the Gaps. Housing and support for people with Dual Disabilities’. VCOSS, Victoria. 14 Ecumenical Housing Inc. et al. (1999) Op. Cit.
5 • radical lack of living skills (chaotic lifestyle, addictive behaviour, inability to maintain physical/mental health, persistent inability to maintain housing and access services) • disruptive behaviour (violent, threatening, aggressive, antisocial, unpredictable; verbal abuse and inappropriate sexual behaviour; frequent encounters with the police; destruction of property) • excessively demanding (resistance to change, manipulative behaviour; recurring/ repeated crises; repeated exclusion from services) • radical lack of social networks (inability to form non abusive relationships; isolation and rejection) • violence to self (depression, confusion, self harm, suicidal, risk taking behaviour, use of alcohol and drugs) 15 Furthermore the report notes that service responses across all typologies can be complicated by factors associated with cultural marginalisation. Within the Type 4 group, duration of need is ongoing, challenging to the service system, and needs are deemed to be high and complex. Although this group is the smallest in number, it requires considerable resources. The researchers chose to develop the typology according to behavioural clusters rather than diagnoses. The report differentiates between multiplicity of need (requiring the arrangement of multiple referrals); intensity of need, and complexity of needs. Hodder et al identify five common mental disorders prevalent amongst homeless people in inner city night shelters in NSW – schizophrenia, alcohol use disorder, drug use disorder, mood disorder and anxiety disorder. Three quarters of homeless people surveyed had at least one of these disorders. 16 Green draws a relationship between the prevalence of mental illness among the homeless population and deinstitutionalisation, insufficient (inner city) low cost housing, and inadequate resourcing of the transfer of the (constructive) functions of institutions to the community. 17 Similarly Wilson refers to the failure to provide adequate housing options for people with mental illness resulting in homelessness in the United Kingdom. 18 A number of authors in the USA in the late 1980s also examined the inadequacy of community care following deinstitionalisation. 19 The literature on homelessness largely defines complex need in terms of clients’ presenting characteristics, and behaviours, in the context of deficits in the service system. The SAAP system is not designed or resourced to provide a specialist response, but as a ‘safety net’ frequently works with people with complex needs. Nevertheless there is a significant number of homeless people, who as a result of a lack of match between their needs and appropriate
15 Ibid. 16 Hodder et al. (1998) ‘Down and Out in Sydney, Prevalence of mental disorders, disability and health service use among the homeless people in Inner Sydney’, Sydney City Mission. 17 Green, D. (2002) ‘Homelessness and mental illness’, New paradigm, April, 3-9. 18 Wilson, B. (1999) ‘Shifts in Mental Health Policy’, Health Policy in the Market State, Hancock, l. (Ed.), Allen & Unwin. 19 Toomey, B, First, R., Rife, J. and Belcher, J. (1989) ‘Evaluating community care for homeless mentally ill people’, Social Work Research & Abstracts, December 1989, Vol. 25, No. 4, 21-26.
6 services, are extremely unlikely to be effectively assisted in the homelessness sector alone. These people are likely to be excluded from services if they are deemed to have extreme levels of high and complex needs. McDonald describes a similar group of homeless people with complex needs, 20 also defining complexity by behaviours rather than diagnostic classification. The Victorian Homelessness Strategy outlines a whole of government approach to homelessness which includes consideration of people with high and complex needs. 21 This is consistent with national directions. 22
2.3 Primary Care Perspectives
Keene (UK based) notes that the literature on complex needs is fragmented, but identifies 5 categories of co-occurring problems (co-morbidity) as a basis for defining complex needs. These include: • psychological, mental health and other problems • learning and developmental difficulties and other problems • social problems, homelessness and other problems • crimes and other problems • drug and alcohol misuses and other problems She proposes a continuum of need, with a significant minority at one end of ‘vulnerable persons who have multiple and usually intractable problems who seek their solutions by attending a number of agencies on a number of occasions’. 23 This minority is seen to preoccupy policy makers, planners and services, are time consuming and resource intensive. 24 This approaches the issue from the perspective of service system capacity as it pertains to presenting needs.
2.4 Disability Perspective
In 2000, the DHS DisAbility Services Division undertook a High and Complex Needs project to explore and identify the support needs of individuals with a disability who have significant and complex behavioural problems. 25 The project defined its target group initially as people with severe behavioural problems who potentially posed a serious risk to themselves and/or others, and
20 Mc Donald, P. (1993) ‘Confronting the Chaos’, A report of the SANS Project, The Salvation Army, Melbourne. 21 Victorian Government Ministerial Advisory Committee (2001) ‘Building Solutions for Individuals and Families who experience Homelessness - Working Report of the Victorian Homelessness Strategy’, Department of Human Services, Melbourne. 22 Commonwealth Advisory Committee on Homelessness (2001) ‘Working Towards a National Homelessness Strategy’, Commonwealth of Australia, Canberra. 23 Keene (2001) Op cit. 24 Bennett, C. (2000) ‘The Victorian Dual Disability Service’, Australasian Psychiatry, Vol. 8, No. 3, 238-242. 25 Victorian Department of Human Services (2000b) ‘Supporting the needs of Individuals with High Complex Behaviours’, DisAbility Services Division, July 2000.
7 who are characterized by high levels of resourcing and incremental restrictions to their lifestyle because of their behaviours. This included people with an intellectual, physical, sensory and/or other cognitive disability who: • are at risk of, or have involvement with the criminal justice system • are Crimes (Mental Impairment Unfitness to be Tried) Act 1997 clients as a specific sub group within the criminal justice system • exhibit severe behavioural problems (often referred to as challenging behaviour) • may have a dual disability (most commonly the co-existence of an intellectual disability and a mental illness, but not exclusively) • have Acquired Brain Injury • have significant drug and/or alcohol abuse issues The description includes people from the Koori community and people from culturally and linguistically diverse backgrounds. The definition of High Complex Behaviours resulting from the Project (with points of clarification in brackets) refers to: “. . . those individuals (including children, adolescents and adults) who have a physical, sensory and/or cognitive disability (as defined under the Intellectually Disabled Persons Services Act 1986 and the Disability Services Act 1986) and who exhibit severe dangerous behaviour that is neither age or culturally appropriate. This behaviour (of a serious and enduring nature) has caused serious harm to the individual, others and/ or property. Without long term support and/or intervention, including ‘control’ in some cases, the behaviour will continue to challenge the usual support services and form significant barriers to the person’s participation and inclusion in society” 26 In the DisAbility Project people exhibiting ‘severe and dangerous behaviours’ are a small sub-population of people at the extreme end of those described with challenging behaviours. The clarification of the definition emphasizes that the responsibility for the behaviour should in no way be located solely with the individual. ‘There is an established relationship between the number of people identified with severe and dangerous behaviour, the health of the service system and the effectiveness of the intervention and support available to them’. 27 The DisAbility report differentiates between people with disabilities (primary level); people at risk of developing high complex behaviours (secondary level); and people who have exhibited high complex behaviours (tertiary level). A service framework is based on these levels which indicates long term support and monitoring for those people included in the definition above. Subsequent research concluded that ‘challenging behaviours’ represent the most common factor identified as leading to a client being labeled complex.
26 Ibid. 27 Ibid.
8 2.5 Dual Disability / Dual Disorder Perspective
The term dual diagnosis originated in the USA during the 1980s when Minkoff 28 and Osher and Kofoed 29 described an integrated model of treatment for people with mental health and substance use disorders. Keene notes that co-morbidity between alcohol and other drug misuse and mental illness has been a major subject of study particularly in the 1990s onwards. 30 Dual disability is described in terms of mental disorders co- occurring with substance abuse; mental health co-occurring with intellectual disability, and intellectual disability co-occurring with substance abuse. Much of the literature focuses on mental illness and substance abuse co-occurring. Another focus is the relationship between dual disability and the criminal justice system. Drake et al 31 note that people with dual diagnosis are heterogeneous and tend to multiple impairments rather than just two illnesses, which adds to complexity. Another complicating factor is diagnostic overshadowing, 32 where one diagnosis (eg. drug and alcohol abuse) takes precedence over, or masks another (such as mental disorder). A Dual Diagnosis Taskforce Report 33 discusses the issue in terms of accompanying medical and social problems, safety issues and multi-system involvement including involvement of child protection, juvenile justice, housing, education and social services in addition to the dedicated mental health, substance use and disability agencies. Other factors associated with substance misuse and severe mental illness, identified from a range of sources include: 34 • heavy use of emergency services • increased suicidal or violent behaviour as inpatients, thereby prolonging hospital stays • poor clinical and social outcomes • violent behaviour • high rates of offending and imprisonment • homelessness
28 Minkoff, K. and Rossi, A. (1998) Co-occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies and Training Curricula’, Report of The Centre for Mental Health Services Managed Care Initiative. 29 Osher, F.C., Kofoed, L.L. (1989) ‘Treatment of patients with psychiatric and psychoactive substance abuse disorder’. Hospital and Community Psychiatry, Vol. 40, 1025-1030. 30 Keene (2001) Op. cit. p1. 31 Drake, R.E., Essock, S.M., et al. (2001) ‘Implementing Dual Diagnosis Services for Clients with severe Mental Illness. Psychiatric Services, Vol. 52, No. 4. 32 Dudley, J., Ahlgrim-Delzell, L., and Calhoun, M. (1999) ‘Diverse diagnostic and behavioural patterns amongst people with a dual diagnosis’, Journal of Intellectual Disability Research, Vol. 43, Part 2, 70-79. 33 Oregon Department of Human Services (2000) Report of the Statewide Taskforce on Dual Diagnosis, D. Walker (Chair). 34 Cupitt, L., Morgan, E., Challeley, M. (1999) ‘Dual diagnosis: Stopping the Merry go round’, ACT.
9 The SUMITT Evaluation includes a review of recent literature on dual diagnosis. 35 The review builds on the literature review that was part of the publication ‘Not Welcome Anywhere’. 36 The SUMITT Evaluation describes ‘Problems of definition and assessment’ and notes that language used to describe dual diagnosis or disability lacks clarity, and that the terms are ambiguous. 37 The terms are used to refer to any number of combinations of sensory, intellectual and physical disabilities, mental illness and substance abuse/ misuse. Mental illness and substance use Disorder (or MISUD) is selected by the writers as the least ‘loaded’ of the terms to refer to one particular co-occuring syndrome. 38 Developments in the UK to broaden research and policy responses to ‘better understand and respond to the complexities of life confronting a vulnerable population’ are outlined in the report ‘Hacking through the net: Review of care for people with severe mental illness and chaotic lifestyles’. 39 This work seeks to define the needs of the small but significant group of people who do not ‘fall’ through the welfare net, but ‘hack’ their way through it. This group has multiple and high support needs, chaotic lifestyles, are difficult to engage and have a severe and enduring mental illness. 40 The report characterizes these people as having one or more of the following: • solitary personalities • risk of dangerousness • history of having been in care as a child • homelessness • substance misuse The Victorian Dual Disability Service presents perspectives on dual psychiatric and intellectual disability, noting the increased number of people with intellectual disability and difficult behaviour not being admitted to institutions. The paper notes the National Mental Health Plan’s commitment to provide improved service access and better responses to people with dual disability including intellectual disability, drug and alcohol misuse and mental disorders. 41
2.6 Personality Disorder Perspectives
In 1993 Linehan published a definitive text on cognitive behavioural treatment of borderline personality disorder (BPD) in women. She notes that in recent years, interest in borderline personality disorder has exploded, due to ‘flooding’ of
35 Lindsay, F., and McDermott, F. (2000) ‘Dual Diagnosis or MISUD (Mental Illness Substance Use Disorder) A review of recent literature’, Psychiatric Disability Services, Victoria. Appended to Fox (2000) Op. Cit. 36 McDermott, F., and Pyett, P. (1993) ‘Not Welcome Anywhere: people who have both a serious psychiatric disorder and problematic drug or alcohol use’, Vols 1 & 2, Psychiatric Disability Services of Victoria (VICSERV). 37 Fox (2000) Op. Cit. 38 Ibid. 39 Cited in Fox (2000) Op. Cit. 40 Ibid. 41 Bennett (2000) Op. Cit.
10 mental health centres by people meeting criteria for BPD, and the ‘woefully inadequate’ treatment modalities. 42 Linehan notes the formal concept of BPD in the fields of psychopathology did not appear until the publication of DSM III in 1980. 43 The official introduction of the term (particularly the term ‘borderline’) was controversial, even though it was widely used in the psychoanalytic community. It was first used by Adolf Stern in 1938 to describe a group of outpatients who did not profit from classical psychoanalysis and who did not seem to fit into the then standard “neurotic” or psychotic” psychiatric categories. Linehan summarises conditions associated with borderline conditions as defined by Stern (1938), Deutsch (1942), Schmideberg (1947), Rado (1956), Elser and Lesser (1965), and Grinker, Werble and Drye (1968). 44 Gunderson (1984) in Linehan summarised four relatively distinct clinical phenomena responsible for the continued psychoanalytic interest over the years in the borderline population: ‘The heterogeneity of the population referred to as “borderline” has led to a number of other conceptual systems for organising (sic defining) behavioural syndromes and aetiological theories associated with the term’. 45 In spite of these differences, the criteria for the new DSM IV ‘were defined by consensus of committees formed by the American Psychiatric Association, based on the combined theoretical orientations of the committee members, data on how psychiatrists in practice use the term, and empirical data.’ 46 Diagnostic criteria (DSM IV) include: 1. Frantic efforts to avoid real or imagined abandonment 2. A pattern of unstable and intense personal relationships characterised by alternating between extremes of idealisation and devaluation 3. Identity disturbance: persistent and markedly disturbed, distorted, or unstable self-image or sense of self 4. Impulsiveness in at least two areas that are potentially self damaging (eg. spending, sex, substance abuse, shoplifting, reckless driving, binge eating) 5. Recurrent suicidal threats, gestures, or behaviour, or self-mutilating behaviour 6. Affective instability: marked reactivity of mood (eg. intense episodic dysphoria, irritability, or anxiety) usually lasting a few hours and only rarely more than a few days 7. Chronic feelings of emptiness
42 Linehan, M. (1993) ‘Cognitive-Behavioural Treatment of Borderline Personality Disorder’, The Guilford Press, NY. 43 Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. 44 Linehan (1993) Op. cit. pp 6,7. 45 Ibid. p 8. 46 Ibid. p 8.
11 8. Inappropriate, intense anger or lack of control of anger (eg. frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress related severe dissociative symptoms or paranoid ideation. 47 Millon (1981, 1987a) in Linehan suggests that BPD can be reached by a number of pathways, resulting from a deterioration of previous, less severe personality patterns. Linehan bases her work on biological theory, stressing the reciprocal interaction of biological and social learning influences in the aetiology of the disorder, but does not develop an independent definition on BPD. 48 She identifies a number of behavioural patterns associated with a sub set of people with personality disorder who have histories of multiple attempts to injure, mutilate or kill themselves. Linehan considers a comparison of BPD and Parasuicidal Behaviour, and implications for treatment. Linehan notes that people who intentionally injure or try to kill themselves, and people in the BPD population, have a number of overlapping characteristics. A particularly noteworthy overlap is that ‘most individuals who engage in non fatal injurious behaviour and most individuals who meet criteria for BPD are women’. 49 Linehan bases her treatment program – dialectical behaviour therapy – on a ‘scientifically sound, non-judgemental and non pejorative theory of BPD’. The idea here is that such a theory should lead to effective treatment as well as to a comprehensive compassionate attitude. Linehan suggests such an attitude is needed, especially with this population – ‘our tools to help them are limited; their misery is intense and vocal; and the success of our attempts to help can have extreme outcomes’. 50 Historically people with severe or borderline personality disorders presented considerable challenges to the service system because they generally did not meet the criteria for mental health or disability services under existing legislation, but their behaviours and needs excluded them from mainstream generalist services. Morton and Buckingham examine service options for people with severe or borderline personality disorders in Victoria. 51 The authors use the term ‘severe or borderline personality disorder’ to include people who would qualify for a diagnosis of ‘borderline personality disorder’ according to the DSM III-R criteria. A significant minority with severe disorders ‘would qualify for other diagnoses including schizoid, schizotypal, paranoid or narcissistic personality disorder’. 52 Based on 1992-93 client data, the consultants estimated that there were approximately 90 people in Victoria with severe personality disorder.
47 Ibid. p 9. 48 Ibid. p 10. 49 Ibid. p 4. 50 Ibid. p 18. 51 Morton, J and Buckingham B (1994) ‘Service options for Clients with Severe or Borderline Personality Disorders’, Psychiatric Services Division, Consultants report prepared by Bill Buckingham and Associates. 52 Ibid. p3.
12 Morton and Buckingham present a summary of theoretical perspectives on severe or borderline personality disorder, as a basis for identifying appropriate treatment options, 53 which focused on aetiology. Subsequent diagnostic systems such as the DSM IV focus on the behavioural manifestations of ‘personality disorder’. The authors note that core difficulties in the disorder are related to affect regulation and the coherence of the ‘self’. There is also increasing agreement on the role of early abuse, neglect and separation in the aetiology of severe or borderline personality disorder. As a result of recommendations made by Morton et al,54 the Department of Human Services funded a specialist service and centre of excellence in the treatment of clients with severe personality disorder. 55 The specialised service, known as Spectrum, defines a ‘very small number of clients with a severe or borderline personality disorder who require intensive individual treatment because of their particularly extreme level and/or type of behavioural disturbance. Typically the level of risk to others and/or the level of distress provoked in others by their behaviour is so high that they pose an unacceptably high risk to any co-clients whether at Spectrum or in a Continuing Care Unit or a Secure Extended Care Unit. Examples of such behaviour might include the following in addition to severe sociality and/or self-harm: · premeditated and/or severe violence to others smearing of infected bodily fluids · the display of particularly gross forms of self harm in a way that is designed to horrify others · severe drug and/or alcohol abuse with a serious risk to others while intoxicated. Many of these clients have been convicted of violent offences against others and many have spent periods in jail. These clients pose a challenge to existing forms of service provision because: · intensive interventions are needed, but can be provided only on an individual basis and not in a ward or group residential environment · they have a range of serious problem behaviours in addition to severe self-harm · effective treatment requires a coordinated service response that crosses service system boundaries - usually involving mental health and forensic services . The vast majority of these clients have a well-documented history of severe abuse and/or neglect. Many of them become homeless because of their extreme behavioural disturbance and thus become vulnerable to further abuse.
53 Ibid. 54 Ibid. 55 Victorian Department of Human Services (1998b) ‘Victoria’s Mental Health Services’, July 1998, Melbourne, p 32.
13 Because of their extreme level of behavioural disturbance it is likely that most such clients would be known to DHS staff, including the Chief Psychiatrist and Spectrum. Many would also be the subject of Ministerial correspondence.’ 56
56 Spectrum (2001) ‘Complex Clients’ Department of Human Services, Melbourne.
14 2.7 Child Protection
The report ‘When Care is not Enough’, 57 described characteristics of the young people in out-of-home care with the highest, most extreme levels of emotional and behavioural disturbance, drawn from 250 adolescents on the High Risk Schedule at the time of the research. Of the 250 young people, 60 were included, deemed to exhibit extreme levels of disturbance, with 200 at immediate risk because of their behaviour. The young people in the research sample were assessed on a series of 10 point scales for: • level of disturbance overall • level of drug use • risk of deliberate self harm or suicide • risk to self from risk-taking behaviour • risk of harm to others All young people were reported to have a history of very severe abuse and neglect (which staff described as horrific), usually commencing before the age of 5 years. In 6 out of 10 cases this included sexual abuse. The study focused on young people aged 11 to 16 with severe emotional and behavioural disturbance. Characteristics of the target group for the study were: • manifest persistent and severe high risk behaviour, including self-harm, involvement with paedophiles and prostitution; • frequently present in states of crisis; • may manifest extreme attachment disorder; • often have mental disorders and/or significant emotional and psychiatric disturbance that may include, suicidal ideas and self-harm behaviour, post- traumatic stress, personality and conduct disorders; • frequently have estranged or non-existent relationships with their family a significantly impaired social relationships with peers and others; • may manifest actual and/or threatened aggression towards others and/or some level of minor offending behaviour; • often have significant drug and alcohol problems; and • often have poor academic achievement and minimal on-going involvement or exclusion from education, training or employment services. The issue of complex needs amongst children and adolescents is frequently approached from a ‘high risk’ perspective where risk amongst young people
57 Morton, J., Clark, R., and Pead, J. (1999) ‘When Care is not Enough, a review of intensive therapeutic residential service options for young people in out-of-home care who manifest severe emotional and behavioural disturbance, and have suffered serious abuse or neglect in early childhood’, Report to Victorian Department of Human Services, Melbourne.
15 aged 12-18 is associated with serious personal or community risk, and the young person poses very difficult management problems. One discussion of complex need within this group approaches the topic from the perspective of theoretical concepts in relation to adolescence, and risk and resilience. 58 In particular the life span theory developmental perspective 59 can accommodate developmental and ecological systems (Frydenberg 1997). Failure of the young person to complete the tasks of ‘developing a positive self-identity, constructive relationship with peers, a sense of self in relation to the social context, and mastery of skills broadly classified as social intelligence . . . may result in a process of maladjustment that is reflected in problem behaviours such as offending, substance abuse and school leaving. 60 Bath identifies an even more concerning group of young people to contain and manage, who are frequently characterised as behaviourally disturbed, seriously emotionally disturbed, and conduct disordered. 61 They are described as young people with serious behavioural and emotional problems together with either a formally diagnosed psychiatric condition, substance abuse dependency, or intellectual disability. Aggression, offending behaviour including violence, aggressive property destruction and theft in care situations and effects on caregivers, are key factors. In a submission to the Social Development Committee, the then Community Services Victoria proposed the following definition of seriously disturbed adolescent behaviour: Those behaviours arising from mental disturbance, which cause serious physical harm or place the physical safety of the person or others in serious jeopardy”. 62 The Committee considered that serious risk behaviours might include: • aggressive behaviours eg. physical assaults • self-injurious behaviours eg. seriously withdrawn, ritualistic or obsessive behaviour which places the person’s health or safety at risk, acts of self mutilation, attempted suicide • serious anti-social behaviour eg. arson, destruction of property which threatens the safety of self or others, high-risk sexual behaviours. In 2000, DHS identified 228 high risk adolescents in its care system (18% of the adolescent child protection population) roughly equal across both genders, posing serious personal or community risk issues and management problems. This high risk group is characterised by complexity and multiplicity of issues, as evidenced by:
58 Success Works (2001) ‘Evaluation of the High Risk Service Quality Improvement Initiative’, Report for Department of Human Services, Melbourne. 59 Branferbreener (1979) in Success Works (2001) Op. Cit. 60 Ibid. 61 Bath (1998) ‘Missing the mark: Contemporary Out of Home Care Services for Young People with Intensive Support Needs’, Association of Children’s Welfare Agencies and the Child and Family Welfare Association of Australia. 62 Victorian Government Social Policy Development Committee (1991) ‘Inquiry into Mental Disturbance and Community Safety, First Report: Young People at Risk’, June 1991.
16 • Challenging behaviour at home, in placement and at school • Substance abuse • Suicidal tendencies • Aggression • Chronic running away • Prostitution • Association with paedophiles • Emerging or diagnosed psychiatric or psychological disorder • Consistent, escalating offending • Sexual offending • Estranged or non-existent relationships with the family 63 Consistent with deinstitutionalisation in other areas, the number of young people in State care in Australia has been declining since the 1970s. 64 The connection between the decrease in young people in residential care (75% fewer children in residential care in 1997 than in 1983) and the increase in homeless children and young people has been noted. 65 Bath also notes that deinstitutionalisation in child welfare has resulted in a concentration of young people with intensive support needs, ‘such that the activity of residential units is in danger of being absorbed by a focus on behaviour control and crisis management to the exclusion of developmental activity’.66 A literature review on high risk adolescents suggests that the group of young people with challenging, multiple and complex behaviours has in part come about through policy and legislative change and subsequent service system redevelopments; and in turn is inadequately serviced by the system.67
The literature on adolescents with complex needs and challenging behaviours is drawn from young people who are or have been in State care, subject to statutory intervention, and/or in juvenile justice centres. 68 A range of texts stress the need to develop early intervention services for children and young adults who would otherwise ‘graduate’ to adult services with a severe or borderline personality disorder. 69
63 Success Works (2001) Op. Cit. 64 Bath (1998) Op. cit. 65 See also Human Rights and Equal Opportunity Commission (1989) ‘Our Homeless Children’, Recommendation 19.5, p 326, and Hage (1989) Op. Cit. p 3. 66 Bath (1998) Op. Cit. 67 Ibid. 68 Lipsey, M., Wilson, D., Cothurn, L. (2000) ‘Effective intervention for serious juvenile offenders’, Juvenile Justice Bulletin US. 69 Ibid. For a review of early intervention literature relating to young people see Davis, C., Martin, G., Kosky, R., and O’Hanlon A. (2000) ‘Early intervention in the mental health of young people: A literature review’, The Australian Early Intervention Network for Mental Health in Young People, Flinders University.
17 2.8 Aspergers Syndrome
The importance of Asperger’s Syndrome in any discussion of high and complex needs is highlighted by several authors. 70 In particular, a number of writers note challenges in providing appropriate responses to children and adolescents with Asperger’s Syndrome. 71 Accurate assessment is seen to be critical because it has direct implications for the types, and effectiveness of intervention. The Victorian Dual Disability Service notes 72that the key challenge for specialist dual diagnosis services is ascertaining the best way to proceed in unusual cases which are not within the ‘normal’ range of a mental health caseload. ‘Patients with autistic features, such as Asperger’s syndrome, appear to pose particular problems as they are difficult to diagnose and can appear to have a psychotic illness and are often brought to the attention of mental health services who remain unsure whether this is a disorder that they can, or should, manage.’ 73 Challenges also arise in the accurate assessment, and subsequent management of behaviours in other syndromes such as over eating in Prader- Willi syndrome, aggressive behaviour associated with a tuberous sclerosis and fragile X syndrome, and regressive behaviours which are not responsive to routine strategies, such as incontinence, intrusiveness, and unpredictable aggression in the context of a psychotic illness. Expertise in mental illness and intellectual disability is important to accurate diagnosis and development of appropriate strategies for care and treatment.
2.9 Criminal Justice Involvement
People with high and complex needs may demonstrate offending behaviour resulting in involvement with the criminal justice system. The way the criminal justice system understands and defines ‘offending behaviour’ of people with high and complex needs, is provided for in a range of legislation, which discussed in more detail in Section 4.3 of this Review. Keene notes that: ‘The link between criminal behaviour and the other problems that feature prominently in the lives of men and women with complex needs -–mental illness, substance abuse, homelessness, unemployment, etc. – is well established and thoroughly documented.’ 74 A number of studies report that people with an intellectual disability at risk of, or involved with the criminal justice system because of offending behaviour,
70 See Tonge, B., Brereton, A., Gray, K., and Einfeld, S. (1999) ‘Behavioural and emotional disturbance in high-functioning autism and Asperger syndrome’, Autism,Vol 3, No. 2, 117-130; Klin, A., Volkmar, F., Sparrow, S., Cicchetti, D. and Rourke, B. (1995) ‘Validity and Neuropsychological Characterisation of Asperger Syndrome: Convergence with Nonverbal Learning Disabilities Syndrome’, Journal of Child Psychology and Psychiatry, Vol. 36, No. 7, 1127-1140; Gray, D. ‘The High Functioning Autism Project’. 71 Klin, A., Volkmar F. (2000) ‘Treatment and intervention guidelines for individuals with Asperger’s Syndrome’. The Guildford Press, NY London. 72 Victorian Dual Disability Service (2001) ‘Development of a statewide Mental health Service for adults with intellectual disability and mental illness’, Paper for THEMS Conference. see www.vdds.org.au/ 73 Ibid. p 5. 74 Keene (2001) Op. Cit. p 17.
18 manifest 6 distinct patterns of behaviour, often associated with complexity of need. These include: - aggressive and disturbing behaviour - withdrawal/ asocial behaviour - inappropriate behaviour - sociopathic characteristics - suicidal or runaway crises - pica disorder. Other studies cite increased likelihood of challenging behaviour/ complex needs in post release situations in the absence of adequate programs. 75 This issue has broader applicability in other areas. Discharge from mental health facilities, prisons and hospitals is often problematic if inadequate or inappropriate discharge planning occurs, and insufficient programs are in place.
2.10 Concluding Comment
The foregoing summary of complex needs is provided as a basis for consideration of legislation, policy, program and service delivery responses. While key aspects from selected areas have been highlighted, other areas require further investigation to provide a comprehensive overview.
75 Ogilvie, E. ‘Post release: The current predicament and potential strategies’, Australian Institute of Criminology.
19 3 GOVERNMENT POLICY FRAMEWORKS
3.1 Introduction
In developing improved responses to people with high and complex needs, Governments have responded by enacting legislation, and through policy and program development. Within each State/Territory, there are several government departments and program areas which have prima facie responsibility or involvement with people with challenging behaviours associated with dual or multiple disabilities/ diagnoses, and complex support needs. Typically governments formulate policies, enact legislation and develop programs in the areas of mental health, disability, substance abuse, housing/ homelessness, child protection, aged care, juvenile justice, primary care and criminal justice. These program areas may be the responsibility of one or more departments. Various inquiries and studies have been undertaken, some in response to particular situations following calls for action by the community. The following section examines government initiatives through policy and program developments, with particular reference to the Victorian situation. Note that Section 4 focuses on legislation. Section 3.2 summarises selected literature reflecting on the effect of the policy of deinstitutionalisation which occurred across many sectors commencing in the late 1960s, and which shaped the way services are provided today. Mental health, disability and drug policies at a national level are covered in Section 3.3, providing broad context. More specific Victorian State policies, identified through a range of literature are discussed in Section 3.4. Based on literature to hand a review of selected policies in Western Australia, South Australia and ACT are provided in Section 3.5. Recent policy initiatives in the United Kingdom are noted in Section 3.6.
3.2 Deinstitutionalisation
Until 50 years ago custodial models of treatment applied to people whose behaviour was deemed to be ‘abnormal’ or unacceptable to the broader community. Such approaches sought to provide comprehensive care in a central location, with specialist staff, and were considered economical to run. However, in the 1960s there commenced a significant shift away from institutional responses to community based responses, ‘based on social justice and moral grounds, and a powerful critique of the efficacy of segregated and congregated care’. 76 In the early 1960s the policy makers in the United States were influenced by Scandinavian experiences in community based services. 77
76 Green (2002) Op. Cit. 77 Bouras, N. and Szymanski, L. (1997) Services for people with mental retardation and psychiatric disorders’, US-UK comparative overview’, The International Journal of Social Psychiatry, Vol. 43, No. 1, 64-71.
20 Similarly, in the UK ‘successive policy initiatives in the 1970s and 1980s shifted priorities towards social care and resettlement from long stay hospitals’. 78 One of the principal shortcomings of care within institutions was that ‘they fostered a lack of independence, choice and privacy’. 79 In considering deinstitutionalisation in the mental health sector, Wilson notes that the move to community based treatment was: 80 • Facilitated by improvements in pharmaceutical treatments • Supported by a human rights perspective that people should be allowed to lead as near to normal lives as possible • Sustained by the belief that institutionalization instilled dependence, exacerbated problems such as mental illness, and created an environment which brutalised both patients/residents and service providers. 81 Several writers acknowledge the overall benefits of deinstitutionalisation, for the majority of people. 82 Young et al report that major reviews of deinstitutionalisation projects in the USA and UK found multiple benefits for people with intellectual disabilities when they were moved from institutions to smaller community based services. They experienced improvements in quality and standard of life, greater independence, and quality of interaction with staff, family and friends. ‘Problem behaviours such as aggression, self-injury, and property destruction have also been observed to decrease in some, but not all, studies when the individual is moved from an institution to a community based living arrangement’. 83 Australian studies are consistent with similar studies in USA and UK. 84 However there have also been a number of concerns, particularly about the way in which deinstitutionalisation has been implemented, the levels of resourcing and the lack of clarity of models of community based care. Some of these concerns are summarised below. In Australia, deinstitutionalisation resulted in a reduction of a significant number of public psychiatric beds. Green cites a study by the Australian Institute of Health and Welfare which reported a reduction from 8,513 beds to 2,759 beds over the 10 year period 1989-90 to 1999-2000. 85
78 Ibid. 79 Wilson (1999) Op. Cit. 80 Most of these issues can be applied to all forms of institutional care including people with disabilities and adolescents in State care. 81 Wilson (1999) Op. Cit. p 253. 82 Hobbs, C., Newton, L. Tennant, C., Rosen, A., and Tribe, K. (2002) ‘Deinstitutionalisation for long- term mental illness: a 6 year evaluation’, Australian and New Zealand Journal of Psychiatry, Vol. 36, 60-66. 83 Young, L., Sigafoos, J., Ashman, A., Grevel, P. (1998) ‘Deinstitutionalisation of persons with intellectual disabilities: A review of Australian studies’, Journal of Intellectual & Developmental Disability, Vol. 23, No. 2. 84 Young et al. (1998) Op. Cit. cites Emerson, E, & Hatton, C. (1996) Deinstitutionalisation in the UK and Ireland: Outcomes for service users. Journal of Intellectual and Developmental Disability, Vol 21, 17-37; and Larson, S.A., & Lakin, K.C. (1989) Deinstitutionalisation of persons with mental retardation: Behavioural outcomes. Journal of the Association for Persons with Severe Handicaps, Vol. 14, 324-332. 85 Green (2002) Op. Cit.
21 There is a view that some mentally ill people who previously would have been institutionalised pose a risk to the community, and there are some people who require full time care, if not segregation. According to Green this view is sustained by changes in social attitudes which include risk aversion and control. 86 However, Mullen and colleagues provide a different view. Comparing rates of criminal offending of people with schizophrenia in Victoria, 87 in the period 1985- 94 (community based services) with the period 1975-84 (institutional based services), he concludes that there is no evidence of increasing criminal behaviour among those with schizophrenia, resulting from deinstitutionalisation. In a subsequent response to correspondence in The Lancet, Mullen acknowledges that this may have been influenced by the establishment of community care in Victoria ‘in favourable circumstances’, and notes ‘in Victoria there has been a substantial investment in the care of mentally abnormal offenders through mental-health services to prisoners, a new secure hospital . . . and a rapidly expanding community forensic mental health service’. 88 Mullen indicates that in order to improve care and reduce crime among the seriously mentally disordered requires several elements, including appropriate medication and medication compliance, ‘social and economic support, integration into work and leisure activities, minimising drug and alcohol abuse, adequate forensic mental health services, and the ready availability of beds for short-term admissions necessitated by relapse or other crisis’. 89 In another paper Mullen notes ‘Deinstitutionalisation and the introduction of community care have not contributed to greater rates of offending among the mentally disordered. No studies exist addressing this question in the intellectually disabled with reference to normalisation policies’. 90 Green claims that the complexity and demanding nature of healing, caring and protective work with young people and adults in community settings has been consistently underrated. This includes responding to people with dual or multiple disabilities. 91 Economic rationalism and an emphasis on throughput has also limited resources and effective responses for those with chronic mental illness requiring long term care. Although deinstitutionalisation was intended to free up funding so that patients could be supported in the community, Burdekin concluded that these funds had been slow in flowing through to the community. In particular viable housing options had not been provided for people with mental illness. 92
86 Ibid. 87 Mullen, P., Burgess, P., Wallace, C., Palmer, S., and Ruschena, D. (2000a) ‘Community care and criminal offending in schizophrenia’, The Lancet, Vol. 355, Feb 19, 614-617. 88 Mullen, P., Burgess, P. (2000b) ‘Community care and schizophrenia’, Authors reply, The Lancet, Vol. 355, May 20, 1827-1828. Note that correspondence in this edition of The Lancet, points to substance use in schizophrenia as a contributing factor to violent behaviour. 89 Ibid. p 1828. 90 Mullen, P. (2001) ‘Mental Health and Criminal Justice’, A review of the relationship between mental disorders and offending behaviours, and on the management of mentally abnormal offenders in the health and criminal justice services’, Prepared for the Criminology Research Council, August 2001. 91 Green (2002) Op. Cit. 92 Human Rights and Equal Opportunity Commission (1995) ‘Human Rights and Mental Illness Victoria’, Report of the reconvened Inquiry into the Human Rights of People with Mental Illness (Victoria), AGPS, Canberra.
22 Accommodation and support needs for people with mental illness are an important issue and often linked to deinstitutionalisation and homelessness. Not only are accommodation options limited due to poverty and lack of low cost housing, 93 but behavioural problems often place tenancies at risk. Mental illness can result in chaotic destabilisation, including hospitalisation, and conflict with landlords, carers and neighbours. 94 Green also suggests that insufficient consideration was given to the accommodation options for people who could not go to their own, or family home. The lack of affordable housing compounded the problem which for many people has led to homelessness. The problem is particularly acute for people with complex needs who have limited accommodation options. 95 In a review of the SANS project (for people with complex needs experiencing homelessness), McDonald reported that most participants had experienced multiple and significant periods of institutionalisation. 96 Ozanne et al note that the policy of deinstitutionalisation/ community living and normalization have increasingly brought people with problematic behaviours in contact with a range of community organisations including the police, alcohol and drug agencies, courts, hospitals, health and community welfare providers. 97 Bouras and Szymanski (1997) note that deinstitutionalisation has been a mixed success, and somewhat dependent on the capability of the communities to provide services. Whereas prior to deinstitutionalisation people with challenging behaviours were catered for in some way within an institutional setting, now agencies and community based organisations can ‘choose whom they will accept, often screening out the more complex individuals or retaining the option of expelling those regarded as too challenging’. This is partly sustained by ‘confusion surrounding the distinction between mental retardation and psychiatric disorder and the difficulty in determining which are primary and which are secondary handicaps’. 98 While the policy objectives of deinstitutionalisation and mainstreaming were intended to provide improved services and reduce isolation and stigma, Green notes that in the rush to close institutions in the late 1980s and 1990s, ‘the stability and structure of the institutions, together with their inherent continuity of care were rarely considered to be of any value. . . . Closures were not accompanied by an adequate conceptualisation or costing of the essential requirements of healing, care and protection of vulnerable people in the community.’ 99 The HREOC (1989) recommended that State and Territory health authorities:
93 Green (2002) Op. Cit.; Wilson, B. (1999) Op. Cit. 94 Harvey, D., Hunter, E. and Whiteside, M. (2000) ‘The accommodation and support needs of people with a mental illness: A process and framework for action’, Australian Social Work, Vol. 53, No. 4, p 8. 95 Green (2002) Op Cit. 96 Ibid. 97 Ozanne, E., Bigby, C., Forbes, S., Glenne, C., Gordon, M. and Fyffe, C. (1999) ‘Reframing Opportunities for people with an Intellectual Disability’, School of Social Work, University of Melbourne. 98 Bouras and Szymanski (1997) Op. Cit. 99 Green (2002) Op. Cit.
23 “urgently revise current policies of deinstitutionalisation to ensure that psychiatrically ill young people are released into the community with appropriate therapeutic and physical support ensure an adequate supply of specialist therapeutic services” 100 The Council to Homeless Persons, 101 supported deinstitutionalisation on the condition that there were available accommodation options, and care and appropriate treatment. Several authors cite Lamb (1984) who suggests that state psychiatric hospitals/asylums fulfilled some very crucial functions for the chronically and severely mentally ill. 102 Wilson also notes that the effectiveness of deinstitutionalisation was limited by resources, and a failure to provide adequate funding to the community sector. Services have become fragmented and localised, resulting in weakened service responses, and less access to specialist resources that were available to people in institutional care. 103 Where community services have been available and comprehensive, most persons with severe mental illness have benefited. However there have been a number of unintended consequences including people who are homeless, or who have been criminalised and who present a significant challenge to the service system. 104 Deinstitutionalisation of children and young people commenced in Victoria in 1975. 105 The impact of deinstitutionalisation on young people in State care has been noted, and is supported as a concept by Morton et al. 106 Burdekin noted that while selected witnesses before the Inquiry into Homeless Children approved of deinstitutionalisation in principle, they also recorded criticisms particularly relating to inadequate support during the transition from institutional to independent living. Indeed, many witnesses attributed youth homelessness to deinstitutionalisation. Witnesses also indicated that there was a clear and continuing need for residential facilities for some young people. 107 Along similar lines, the Morris Report noted that ‘deinstitutionalisation has been embraced without developing and resourcing sufficient alternative community support or care options. This was argued as contributing to homelessness among young people . . . ‘ 108 While concerns persist that the provision of services by the community sector have not been sufficiently planned and resourced following deinstitutionalisation,
100 Human Rights and Equal Opportunity Commission (1989) “Our Homeless Children”, Report of the National Inquiry into Homeless Children by the Human Rights and Equal Opportunity Commission (Burdekin, Chair), AGPS, Canberra. 101 Hage, M. (1989) ‘People with mental disorder and homeless’, Council to Homeless Persons, Victoria, p 4. 102 Lamb E. H. (ed.) (1984) ‘The Homeless Mentally Ill’, APAP, Washington 1984. 103 Wilson (1999) Op. Cit. 104 Lamb, H.R., and Bachrach, L.L. (2001) ‘Some perspectives on Deinstitutionalisation’, Psychiatric Services, Vol. 52, No. 8, 1039-1045. 105 Jaggs, D. (1990) ‘Institutions for Children and Young People 1850-1980’ School of Community Services and Policy Studies, Phillip Institute of Technology, Melbourne. See also Jaggs, D. (1986) ‘Neglected and Criminal: Foundations of Child Welfare Legislation in Victoria’, Phillip Institute of Technology, Centre for Youth and Community Studies. 106 Morton et al. (1999) Op. Cit. 107 Human Rights and Equal Opportunity Commission (1989) Op. Cit. 108 House of Representatives Standing Committee on Community Affairs (1995) ‘Inquiry into Aspects of Youth Homelessness’, A. Morris (Chair), Canberra.
24 and particularly affecting some groups, 109 and in the absence of evidence to the contrary, the rationale and overall outcomes of deinstitutionalisation are nevertheless generally supported.
3.3 National Policy Context (Australia)
Mental Health In the early 1990s considerable changes unfolded in mental health policy and planning. The National Mental Health Strategy includes The National Mental Health Policy (1992), The National Mental Health Plan (1992), and the Mental Health Statement of Rights and Responsibilities (1992). These were agreed to by all Health Ministers, and provided an agenda for change. Since 1992 there have been a series of annual reports describing progress. 110 The Second National Mental Health Plan commenced on July 1 1998 and terminates on 30 June 2003. A formal evaluation will be completed in 2003. The Second Plan emphasises promotion and prevention, partnerships in service reform, and quality and effectiveness of services. 111 Policy changes have included an increasing emphasis on early intervention in the mental health of young people,112 and agreement on the target group for forensic mental health services. 113 Targeted populations in the Second Plan included people with mental illness and intellectual disability or problems with drug and alcohol misuse. In 1996, National Standards for Mental Health Services were developed.
Disability The provision of disability services in Australia is established by the Commonwealth State Disability Agreement (CSDA). A review of the Agreement conducted in 1996 provided input to policy development at Commonwealth and State/Territory levels. 114 A review of policy development in intellectual disability is contained in Ozanne et al (1999).115
Drug Strategies In 1985 a joint Commonwealth State strategy was established. Initially named the National Campaign Against Drug Abuse, it was subsequently changed to the
109 Human Rights and Equal Opportunity Commission (1995) Op. Cit. 110 For example, see Commonwealth Department of Health and Aged Care, Mental Health Branch (1998) National Mental Health Report 1997. Fifth Annual Report. Changes in Australia’s Mental Health Services under the National Mental Health Strategy. 111 For example, see Commonwealth Department of Health and Aged Care, Mental Health Branch (1999) Mental Health Promotion and Prevention National Action Plan. 112 See for example Davis, C., Martin, G., Kosky, R., and O’Hanlon A. (2000) “Early intervention in the mental health of young people: A literature review”, The Australian Early Intervention Network for Mental Health in Young People, Flinders University. 113 Mullen, P., Briggs, S., Dalton, T., and Burt, M. (2000c) ‘Forensic Mental Health Services in Australia’, International Journal of law and Psychiatry, Vol 23, No 5-6, p 438. 114 Yeatman, A. (1996) ‘Getting Real’, The final report of the review of the Commonwealth/State Disability Agreement, AGPS. 115 Ozanne et al. (1999) Op. Cit.
25 National Drug Strategy. The aim of these strategies has been to minimise the harmful effects of drug use in Australian society. An evaluation of the National Drug Strategy was undertaken in 1997. 116 Following this the National Drug Strategic Framework 1998-99 to 2002-03 Building Partnerships, was endorsed by the Ministerial Council on Drug Strategy. 117
3.4 Victoria - Policy and Program Development
Mental Health The release of ‘Victoria’s Mental Health Service: The Framework for Service Delivery’ (1994), has resulted in a number of initiatives and changes to mental health service provision. The proposed developments were consistent with the National Mental Health Policy, and by 1996, 22 Area Mental Health services had been established in Victoria. The next major policy release was in 1998, by which time several key aspects of the Framework had been achieved. 118 While much of the policy thrust was around moving to community based services, there were four key initiatives relevant to people with complex needs: • development of a specialist service for prisoners who have a mental disorder • development of the Victorian Institute of Forensic Psychiatry • development of a specialist service and centre of excellence for the treatment of clients with severe or borderline personality disorder • development of a policy framework for Aboriginal people with serious mental illness. The need to improve services for people with personality disorders was also recognized as part of the work of the Victorian Suicide Prevention Task Force: ‘There is considerable evidence linking suicide with a number of forms of mental illness, particularly depression, schizophrenia, bipolar disorder, conduct and personality disorders and eating disorders’. As part of the consultation process a number of people expressed concerns to the Task Force about the service response to people with a personality disorder: ‘the service response is often crisis driven and ad hoc’, despite recent changes to the Mental Health Act 1986, which provided for involuntary treatment for people with personality disorder. 119 The Task Force recommended the establishment of a specialist Statewide service. In 1998 the Victorian Institute of Forensic Mental Health, known as Forensicare, was established. 120 Services include:
116 Single, E., & Rohl, T. (1997) ‘The National Drug Strategy: mapping the future’, Evaluation of the National Drug Strategy 1993–1997 commissioned by the Ministerial Council on Drug Strategy, AGPS, Canberra. 117 Ministerial Council on Drug Strategy (1998) ‘National Drug Strategic Framework 1998-99 to 2002- 03 Building Partnerships’, AGPS, Canberra. 118 Victorian Department of Human Services (1998a) The Framework for Service Delivery, Better Outcomes Through Area Mental Health Services, Melbourne, July 1998, p 2. 119 Victorian Government (1997) ‘Suicide Prevention’ Task Force Report, June, 1997, p. 105. 120 For example, Glaser, W., and Florio, D. “A community forensic dual disability service: the first ten months” www.forensicare.vic.gov.au/research/research.html
26 • The Thomas Embling Hospital, located in Fairfield, which provides inpatient assessment and treatment in acute and continuing care programs for up to 80 people. A specialist women's program is also provided. • Community Forensic Mental Health Service, located in Brunswick, which provides treatment programs to a varied outpatient group, together with advice, assessments and reports to Victorian courts as requested. • Prison Services provide mental health care at the Melbourne Assessment Prison (including an acute assessment unit for the mentally ill), and the other publicly operated prisons in Victoria. The Substance Use and Mental Illness Treatment Team (SUMITT) was established in 1998 as pilot project. It was evaluated in June 2000 and it was recommended that it be recurrently funded, and extended. SPECTRUM, the Statewide Specialist Personality Disorder Service, based at Maroondah Hospital, was established in 1999. It provides services to clients with complex needs who present with very severe and frequent self harm and low to moderate levels of aggression and episodic impulsive violence. The Victorian Dual Disability Service (VDDS), based at St Vincent’s Hospital, was established in 1999 to provide services to people over the age of 16 who have an intellectual disability and a psychiatric illness. The main work of the service is to inform assessments, provide secondary consultation and training to staff working in each of the 22 Area Mental Health Services, and facilitate a coordinated response. The model is described by Bennett (2000). 121 Child and Adolescent Mental Health Child and Adolescent Mental Health Services (CAMHS) provide services to seriously disturbed children and adolescents and those most at risk for developing severe disturbance. Services include assessment and consultation, out patient treatment, brief admission to CAMHS in-patient units, day programs and medium term in-patient treatment in some regions. 122 In addition an Intensive Mobile Youth Outreach Service (IMYOS) was established in 1998 to engage, assess and treat young people with severe and complex disorders, who have been difficult to engage using office based approaches. Mental Health Intensive Youth Support Services (MHIYSS) provide mental health assessment, treatment and consultation for the clients of the Intensive Case Management Service established by regional Child Protection Services. Disability A DisAbility Services Draft Plan was completed in January 2002. 123 The Plan proposes strategies which include: • a system more focused on individuals, and an approach which is flexible and tailored to individuals, and which links individuals with their local communities and supports.
121 Bennett (2000) Op. Cit. 122 Morton et al. (1999) Op. cit. 123 Victorian Department of Human Services (2001d) ‘Draft State Disability Plan’, Melbourne. See [http://hnb.dhs.vic.gov.au/ds/disabilitysite.nsf/pages/plan?Open]
27 • making the disability support system more responsive to people who have high complex behaviours • enhanced mechanisms to protect the rights of people with a disability including ‘an effective, open and transparent way of authorising, reviewing, regulating and monitoring service practices that restrict the rights and liberties of people who are receiving disability support • improved linkages and supports for people in contact with the criminal justice system, including working in conjunction with Juvenile Justice to develop strategies for the management of young people in custody or under community orders, and strategies for their release; and working with the Department of Justice to further develop models of support, and to divert people with a disability from the criminal justice system, where appropriate. Many of the proposed strategies will be considered as part of the review of relevant legislation by the Victorian Law Reform Commission. 124 Victoria has established a separate program and associated facilities for offenders with an intellectual disability, under the Disability Services’ Criminal Justice Program. Funded through the Department of Human Services, the program commenced in 1986, and is governed by the Intellectually Disabled Persons’ Act 1986. The program comprises: • The Statewide Forensic Service including the Intensive Residential Treatment Program, the Long Term Residential Treatment Program and provision of support to prisoners within the criminal justice system. • Two crisis emergency houses • The Australian Community Support Organization • Jesuit Social Services 125 A review of the DisAbility Services’ Criminal Justice Program was undertaken in 2000, and a number of recommendations were made. 126 The review included a review of relevant literature, and a summary of programs in the UK, USA, Canada and in Western Australia. Protection and Care The Department of Human Services’ Community Care Division provides a range of services. 127 Intensive Case Management Services (ICMS) provide a multi- disciplinary intensive case management service to young people who are subject to statutory (Child Protection) intervention. In addition two key initiatives for young people with complex needs are Secure Welfare Services and the High Risk Adolescent Quality Improvement Initiative. Secure Welfare Services
124 Victorian Law Reform Commission (2002) ‘People with Intellectual Disabilities at Risk: A legal Framework for Compulsory Care: Discussion Paper’, Victorian Law Reform Commission, Melbourne. 125 Social Equity Consulting Group (2000), ‘DisAbility Services’ Criminal Justice Program Strengthening Service Provision’, A report prepared by Bunting et al. in association with Dr Meredith Martin for the Victorian Department of Human Services, Melbourne. 126 Ibid. 127 Victorian Department of Human Services (2000d) ‘Working Together Strategy Program Description Paper’, Melbourne, pp 10-12.
28 provides short term secure residential care for young people at immediate and substantial risk. The High Risk Adolescent Service Quality Improvement Initiative was implemented in 1998 following a review of practice. The Initiative targeted high risk adolescents within the Protection and Care Program through three main service components: • Intensive Case Management Service (ICMS) • One to one home based care • Brokerage funds The Initiative was evaluated in 2001, and recommendations made for it to continue.128 Descriptions of other programs relevant to young people at risk and with challenging behaviours are found in The Working Together Strategy Program Description Paper. 129 Juvenile Justice Juvenile Justice seeks to divert minor offenders from the criminal justice system and provide rehabilitation and post release support for more serious offenders, in 3 Juvenile Justice Centres for young people sentenced to a period of detention, at Parkville, Melbourne and Malmsbury. 130 Morton et al. (1999) note that the Parkville Youth Residential service is particularly relevant for young people with severe emotional and behavioural disturbance. 131 Juvenile Justice provides a range of other services including statutory case management of young people on community based orders. Drug treatment Services As part of the National Drug Strategy, the Victorian Government established a 5 year Strategic Plan in 1993. Large institutions were closed in 1994, and a range of community based services were established including drug withdrawal services, counselling and support services, and specialist methadone services. In 1996 the Government announced the ‘Turning the Tide’ initiative, following a report by the Premier’s Drug Advisory Council. 132 This significantly strengthened community based responses, particularly focusing on young people. 133 The government also recognised the growing importance of addressing dual disability.
128 Success Works (2001) Op. Cit. 129 Victorian Department of Human Services (2000d) Op Cit. 130 Ibid. p18. 131 Morton et al. (1999) Op Cit. p. 33. 132 Victorian Government, Premier’s Drug Advisory Council (1996) ‘Drugs and the Community’, Prof. David Penington (Chair). 133 Victorian Government Department of Human Services (1997c) ‘Victoria’s Alcohol and Drug Treatment Services. The Framework for Service Delivery’, Aged, Community and Mental Health Division.
29 The Working Together Strategy The Working Together Strategy was established in 1999 to provide a framework for inter sectoral service provision and to improve service quality for young people receiving services from the Department of Human Services. 134 The Working Together Strategy involves four programs which provide services to children and adolescents – Child Protection, Mental Health Services, Drug Treatment Services and Juvenile Justice. The Strategy seeks to find creative and collaborative approaches to responding to young people with high complex needs. The priorities and activities of the Working Together Strategy are outlined in the Working Together Strategy Document (DHS, 1999). In May 2000 a Program Description paper was produced to help ensure that all programs understand each other’s roles, agency structures and practices. Multi Service Client Project The Multi Service Client Project originated in 1999 as a result of concern that a number of individuals were accessing more than one of Department of Human Services’ services, and that the joint delivery of these services was not optimal, or sufficiently coordinated. 135 Key recommendations included: • developing a capacity to identify the nature and extent of multi service use • progressing the design of multi-service client case management • determining information management requirements A cross program coordination framework was developed and two pilot projects were developed in Western Metropolitan and Grampians Regions, to trial the concept of cross program coordination. Progress reports have been produced on both of these pilots. 136 Victorian Homelessness Strategy While the provision of services to people experiencing and at risk of homelessness is primarily mandated by the Commonwealth SAAP Act, policy and program development is substantially devolved to the States and Territories. The Victorian government has long recognised the relative level of people with complex needs represented in the population of people experiencing homelessness. It funded the SANS Program in 1991/92, and established the mental health Homeless Outreach Program in 1995. The government has subsequently funded a range of intensive support programs for young people and single adults, through different program areas, including SAAP, Office of Youth Affairs and Mental Health. The current Victorian Homelessness Strategy (VHS) recognises the importance of providing services to people with complex needs. The VHS notes ‘the needs of people experiencing or at risk of homelessness can be extremely complex
134 Victorian Department of Human Services (1999b) ‘The Working Together Strategy. A Quality Improvement Initiative involving Mental Health, Protection and Care, Drug Treatment Services and Juvenile Justice’, February 1999. 135 Victorian Department of Human Services (1999a) ‘Managing Clients Initiative. Multi Service Clients Project Problem Definition Phase’ February 1999. 136 Victorian Department of Human Services (2001c) ‘Complex Clients Regional Overview’, Unpublished, DisAbility Services, Melbourne.
30 and require a multi-faceted response’. 137 Also: ‘People with serious mental illness and psychiatric disability who are homeless present a significant challenge to homeless and broader services’. 138 The VHS also recognises the importance of providing a whole of government response to homelessness, and proposes several directions for change. These include an Inter-Departmental Committee on Homelessness, multi-faceted responses to young people, developing employment opportunities, and seeking to integrate homelessness assistance into the primary care service system. 139
3.5 Selected Policy Contexts of Other States and Territories
Western Australia Rayner and Cockram provide an historical review of the response of the criminal justice system to people with intellectual disability in Western Australia. They note that it was not until 1985 with the enactment of the Authority for Intellectually Handicapped Persons Act 1985, that statute law gave positive recognition to people with intellectual disabilities. ‘The recognition by law that intellectual disability was not a mental illness and that people with intellectual disabilities had the full range of human rights and dignities was a major achievement in a State where previously the primary legal response had been to detain this group and forget them’. 140 Since 1996, the Western Australian government has been developing and improving mental health services in the State. A Ministerial Taskforce on Mental Health developed a blueprint to reform services and legislation. 141 A Strategic Plan for mental health services (which includes a literature review) was subsequently developed for the South West Metropolitan Corridor.142 South Australia Dame Roma Mitchell reviewed services for persons with severe personality/behaviour disorders with particular emphasis on those presenting with associated intellectual handicap (of borderline level) or brain damage. Mitchell assessed care needs required for the protection of themselves and others; examined deficiencies in service provision; and made recommendations on appropriate responses in terms of care and legislation. 143 Key recommendations included:
137 Victorian Department of Human Services (2002b) ‘Victorian Homelessness Strategy: Action Plan and Strategic Framework’ Melbourne. 138 Victorian Government Ministerial Advisory Committee (2001) Op. Cit. 139 Victorian Department of Human Services (2002b), Op Cit. pp 82-95. 140 Rayner, M. and Cockram, J. (1996) ‘The response of the law to intellectual disability in Western Australia 1829-1993’, in Under Blue Skies: the social construction of intellectual disability in Western Australia, p 158. 141 The Western Australian Health website (www.health.wa.gov.au/SouthWest/) cites the Mental Health Taskforce (1996) and Smith, McCavanagh, Williams & Lipscombe (1996) “The Mental Health Plan’. 142 Western Australian Department of Human Services (2002) ‘Strategic Plan for Mental health Services in the South West Corridor’, Perth. 143 Mitchell, Dame R. (1985) ‘Report of the Review of Services for behaviourally Disordered Persons in South Australia, Adelaide, May 1985.
31 • The establishment of a multi-disciplinary assessment panel to diagnose a person’s condition and assess whether any treatment is required. • The establishment of a Management Committee which seeks to ensure that services are coordinated in the most cost effective way possible. The Committee would work closely with the Guardianship Board. • That people suffering from severe behavioural disorder be covered by the Guardianship Board • The development of appropriate facilities and services. • Measures to protect the rights of people subject to the provisions. The Management Assessment Panel for behaviourally disordered persons was established in 1987. There is a permanent Unit comprising a Chief Executive Officer, 2 half time social workers, and administrative staff. The Panel is formed when required, from a pool of about 80 professionals from various government departments. Australian Capital Territory A similar arrangement has evolved in ACT. The Community Advocate has statutory responsibilities in relation to people with disabilities, including people with either a mental illness or mental dysfunction, who are caught up in the criminal justice system (ie forensic clients). A Management Assessment Panel was established within the Office of the Community Advocate in 1997. ‘Its role is to assist in the task of finding solutions for individuals (children and adults) whose behaviour presents a risk to themselves or the community, whose situations require coordinated interventions across several service systems, and for whom the systems have failed to find solutions’.144 The initial role of the MAP Office is to achieve better coordination through persuasion. Where this is ineffective a Panel is convened. People placed on a Community Care Order under the Mental Health Act, are the responsibility of the Care Coordinator. The Care Coordinator develops a care plan involving the Community Advocate, the Mental Health Tribunal and the person or guardian. The Care Coordinator has a Memorandum of Understanding with several key government organisations. 145 The Executive Officer of the Management Assessment Panel has been delegated all of the functions and powers of the Care Coordinator and vice versa. In researching treatment options for people with dual diagnosis (mental illness and alcohol or drug issues) Cupitt describes the policy context and current practice in ACT.146
144 ACT Corrective Services (2001) ‘Working with Female Offenders Forum’, Summary of Presentation by Ms Heather McGregor, ACT Community Advocate, p 28. 145 ACT (2000) Memorandum of Understanding between The Care Coordinator and Canberra Hospital, the Department of health and Community care, the Department of Education and Community Services and the Department of Justice and Community Safety. 146 Cupitt et al.(1999) Op. Cit.
32 3.6 United Kingdom
Since 1997, the British Government has been set on a path of policy development to address high risk patients and in particular people with Dangerous and Severe Personality Disorder (DSPD) who pose a risk of serious offending. There are estimated to be approximately 2000 people who fall into this group in England and Wales. Under existing arrangements there are concerns that the law and therapeutic treatments are considered insufficient to protect the community. The Government produced ‘Proposals for Policy Development’ in 1999, seeking comments from the community. Two options were proposed. The first was based on retaining and strengthening the existing legislation to ensure that DSPD people would not be released from prisons or health services while they continued to present a risk to the public. Under the second option a new legal framework would be introduced which would provide for the indeterminate detention of DSPD people, and they would be held separately. 147 “In many cases an individual who has a dangerous severe personality disorder has to be released from prison at the end of a determinate sentence even though they are assessed as presenting a continuing risk of harm to others.” These people “are rarely detained under the Mental Health Act 1983 because they are assessed as being unlikely to benefit from the sorts of treatment currently available in hospital”. 148 The proposals sought to address both deficiencies in the law and lack of service provision. The second option was chosen, thus requiring significant reforms the Mental Health Act 1983. This is discussed further in Section 4.3.
147 Home Office and Department of Health (1999) ‘Managing Dangerous People with severe personality disorder, proposals for policy development’, Department of Health, London. 148 Home Office and Department of Health, United Kingdom (2000), ‘Reforming the Mental Health Act, Part II High Risk Patients’, December 2000, p 9.
33 4 LEGISLATIVE CONTEXT RELATING TO PEOPLE WITH HIGH AND COMPLEX NEEDS
4.1 Introduction
There is a range of legislation covering people with high and complex needs. In most Western countries the important provisions are found in mental health, disability, and criminal justice legislation, with most of the relevant legislation enacted at State/Provincial level rather than at Commonwealth level. While this section focuses on relevant legislation in the state of Victoria, there is obviously a wealth of relevant literature to be found in other states in Australia and overseas. Section 4.2 considers the national context for legislative reform, which appears to mainly derive from a human rights framework, as well as through selected Commonwealth legislation. Section 4.3 reviews literature on Victorian legislation, covering several Acts, including historical developments in recent years. Selected literature discussing legislation in other Australian States and Territories is reviewed in Section 4.4. Section 4.5 deals with recent changes to UK legislation relating to people with dangerous and severe personality disorders, and Section 4.6 briefly touches on literature which refers to other relevant overseas legislation.
4.2 National Context
Legislative reform relating to people with high and complex needs has generally not been driven at the national level. Each State and Territory has several relevant pieces of legislation dealing with detention, sentencing, treatment, protection and care and guardianship. ‘Wide discrepancies between the states and territories grew with regard to mental health laws and the law relevant to the mental health element in crime’. 149 A review of the differences in legislative provisions for mentally disordered offenders in Australia in 1994 is provided by Freiberg.150 Mullen describes the legal context to forensic mental health services in Australia. In 1995 the Standing Committee of Attorneys General of the States and the Commonwealth put forward a Model Criminal Code, intended for adoption by all Australian jurisdictions. For the first time the defence of mental impairment was extended to include severe personality disorder. Mullen notes that the Model Criminal Code ‘is being adopted by the various states, but with modifications that are maintaining or, in some cases, augmenting differences’. 151
149 Mullen et al. (2000c) Op. Cit. p 435. 150 Freiberg, A. (1994) ‘The Disposition of Mentally Disordered Offenders in Australia: ‘Out of Mind, Out of Sight’ Revisited’, Psychiatry, Psychology and Law, Vol 1, No. 2, 97-118. 151 Mullen et al. (2000c) Op. Cit. p 436.
34 Human rights agreements and declarations have also formed important context for the development of legislation dealing with detention and treatment of people with high and complex needs. 152 Australia is party to the International Covenant on Civil and Political Rights (ICCPR). Burdekin noted that arbitrary detention has two aspects ‘. . . whether detention is subject to legal control, including sufficiently ascertainable standards . . . and whether detention is reasonably justified by reference to a legitimate purpose.’ 153 Other United Nations provisions include: • The Declaration of the Rights of Disabled Persons • The Declaration on the Rights of Mentally Retarded Persons • The Declaration of the Rights of the Child • Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care 154 These and other provisions are in part legislated through the Federal Human Rights and Equal Opportunity Commission Act. Through this legislation, the Commission conducted a major review of human rights and mental illness in 1993. 155 The Commission identified ‘an appalling lack of regard for human rights throughout much of the public psychiatric system’,156 and made many significant recommendations for reform. The Victorian Law Reform Commission notes the importance of identifying the human rights principles on which laws relating to compulsory care for people with intellectual disabilities, should be built. The Commission discusses the application of the Declaration of the Rights of Disabled Persons and Mentally Retarded Persons. 157 In addition, various Commonwealth Acts make reference to the rights of Australian citizens through the recognition of international standards, conventions and declarations. For example, the basis for the Supported Accommodation Assistance Act 1994 is the protection of rights of all citizens, including people who are homeless and at risk of homelessness.
152 In some areas this is reflected more in government policies rather than in legislation. 153 Victorian Government Social Development Committee (1992a) ‘Inquiry into Mental Disturbance and Community Safety, Third Report. Response to the Draft Community Protection (Violent Offenders) Bill’, p 70. 154 Human Rights and Equal Opportunity Commission (1993) ‘Human Rights and Mental Illness’, Report of the National Inquiry into the Human Rights of People with Mental Illness. Vols 1 & 2, AGPS, Canberra, pp 21-31. 155 Ibid. 156 Goonan, G., Healy, B., Moynihan, P. (2000) ‘The Death of the Subject. Human Rights, Due Process, and Psychiatry’, International Journal of Law and Psychiatry, Vol. 23, No. 1. 23-41. 157 Victorian Law Reform Commission (2002) Op. Cit.
35 4.3 Victoria
Introduction In the 1970s and 1980s, consistent with trends in Australia and overseas, Victoria implemented closure of institutions (asylums) for people with mental illnesses, disabilities and drug issues. Deinstitutionalisation also affected young people in State care. In Victoria, several Acts provide the legislative basis for both mandating and circumscribing a response to numbers of people with complex needs and behaviours. In 1986 the Victorian parliament passed three Acts, replacing the Mental Health Act 1959. These Acts were: • The Mental Health Act 1986. • The Intellectually Disabled Persons’ Services Act 1986, and • The Guardianship and Administration Board Act 1986, now called the Guardianship and Administration Act 1986. The Mental Health Act 1959 had provided a basis for service provision to people living in institutional environments. The new package of legislation was more appropriate to the context of deinstitutionalisation, that had been occurring since the late 1970s. 158 Other Victorian legislation relevant to people with high and complex needs includes: • The Community Protection (Violent Offenders) Act 1993 • The Intellectually Disabled Persons’ Services Act 1986 • The Sentencing Act 1991 • The Children and Young Persons Act 1989 • The Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 • The Alcoholics and Drug-dependent Persons Act 1968
Victorian Government Social Development Committee In the late 1980s and early 1990s there was an unprecedented level of interest in detention of people with mental disorders and the perceived associated threat to community safety. In 1989 the Victorian Government Social Development Committee undertook an ‘Inquiry into Mental Disturbance and Community Safety’. 159
158 Tait, S. (2001) ‘Disability Law Reform’. Paper delivered at the Guardianship and Administration National Conference, Melbourne, 19th October, 2001. 159 Victorian Government Social Development Committee (1992) ‘Inquiry into Mental Disturbance and Community Safety’, Fourth and Final Report. Note that the work of the Social Development Committee spanned 3 years from 1990 to 1992, and produced 5 reports. The Committee produced an Interim Report (May 1990) which focused on people with serious personality disorder with or without a mental illness who are deemed dangerous. The First Report (June 1991) examined whether children and young people with mental disturbance could pose a threat to community safety. The Second Report (March 1992) addressed the draft Community Protection
36 The Committee was required to: • Identify the dimensions, scope and impact on families and within the community of violent or criminal actions by people evidencing seriously disturbed behaviour associated with mental illness, intellectual disability, acquired brain damage or personality disorder • Examine existing legislation dealing with such people • Examine the role and relationships of agencies involved . . . • Make recommendations for action required to remedy any deficiencies or gaps in current policies, strategies and systems necessary to ensure the safety and well-being of individuals as well as the community in general, including recommendations on legislative change if required. In its Fourth and Final Report the general thrust of the Committee’s recommendations was for the provision of additional resources in the form of individual case management, with responses and resources allocated according to need (for example, Recommendations 67 and 68). The Committee recognized that more work was required to define the extent and nature, and appropriate responses to people with mental illness and alcohol and drug problems (Recommendation 69). Although a number of recommendations were made in relation to amending legislation, these mainly related to appropriate sentencing and detainment responses to offenders, and administrative matters. The need for Departmental cooperation was highlighted as an issue (Section 1.2.10, Recommendation 23, 24) The importance of interdepartmental cooperation was regarded as especially important for people with dual and multiple disabilities who at times fall into service gaps ‘because they do not neatly fit the criteria for any particular service’ (:244) In particular, the Committee suggested that legislative changes ‘meant that there is now a great deal of confusion and uncertainty surrounding the treatment and supervision of people with intellectual disabilities who also require psychiatric treatment’. Community Protection (Violent Offenders) Act As part of its work, in 1991/92, the Social Development Committee considered and responded to the draft Community Protection (Violent Offenders) Bill. This Bill had been developed by Parliament in response to the anticipated release from prison of Garry David, who had made serious threats of violence towards the community. The Committee recommended that the proposed Bill not proceed, arguing that the provisions of the Bill were unnecessary, misconceived and likely to erode human rights. The Committee noted that there were various release schemes including provisions under the Sentencing Act 1991 which should be sufficient. 160 The Committee received a number of submissions from psychiatrists, members of the legal profession, civil liberty groups and welfare organizations, most of whom argued against the proposed legislation.
(Violent Offenders) Bill. The Third Report constituted he Committee’s response to the draft Bill. The Final report (August 1992) draws together a number of the issues in the previous reports. 160 Victorian Social Development Committee (1992a) Op. Cit.
37 Despite the recommendation made by the Committee, the Community Protection (Violent Offenders) Act was passed. A similar case in NSW around the same time led to a similar Act being passed there. 161 The Victorian Act applied only to offenders who had committed serious offences, and who were considered dangerous because of a severe diagnosed personality disorder. Prior to, and following the passing of the Bill, there was considerable discussion and debate about the unusual nature of the Bill, and a number of issues for concern were identified. Principal concerns expressed in the literature of the day are summarized below. Parliamentary autonomy A number of authors considered that the Act was expedient and a ‘quick fix’, without adequate public debate, and there was no Law Reform Commission report on community protection prior to the Act being drafted and considered. 162 Concerns were expressed that the Act was unconstitutional in that Parliament was attempting to curtail fundamental human rights. 163 Mead examined the separation of powers (between Parliament and the Courts), and suggested that the Act placed Courts in an invidious position. The Act was so focused, that by not placing David in detention, Courts would frustrate the sole purpose of the Act. 164 Thomson suggested that in so doing, Parliament had usurped the role of others (ie the Courts, the Office of Corrections and the Health Department). 165 Greig noted that the legislation joined the interests of Parliament, the Supreme Court, the Office of Corrections and the Health Department, although the pattern of relationships was not clear. Greig suggested that the Act was sustained by political and sociological elements. 166 Violation of rights Several authors claimed that the Act allowed fundamental rights to be violated. The Act appeared to violate several legal dictums including equality before the law, presumption of innocence, onus of proof, proportionality (in sentencing), and restrictions on preventive detention which was disallowed under common law. It was argued that the criminal justice system could not deal with a
161 Fairall, P. (1995) ‘Imprisonment without conviction in NSW.: Kable v Director of Public Prosecutions’, Sydney Law Review, Vol 17, No 4, 573-580. 162 Merkel, R. (1992) ‘Submission to the Social Development Committee: Community Protection (Violent Offenders) Bill’, Victorian Council for Civil Liberties, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, p 76. 163 Keon Cohen, B. (1992) ‘Can the Victorian Parliament abolish fundamental rights?’, Proceedings of Conference, Australian Institute of Criminology, October 1991, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 29-44. 164 Mead, G. (1991) ‘Sentencing – the problem of balancing freedom and incarceration for persisting offenders and a discussion Victoria’s Garry David legislation’, Paper presented to CLE Seminar, Law Society of South Australia. 165 Thomson, D. (1990) ‘Civil liberties aspects of preventive detention of dangerous persons, focusing on the case of Garry Webb’. Paper presented to the Rationalist Society of Australia 54th Conference, Warburton, Victoria. 166 Grieg, D. (1993) ‘The Politics of Dangerousness’, in ‘Serious violent offenders: sentencing, psychiatry and law reform’, Proceedings of Conference, Australian Institute of Criminology, October 1991, 47-66.
38 potential offender as protective sentencing had been rejected by the High Court as part of Australian common law. 167 Williams noted that criminal incarceration is based on retribution, for crimes committed, and not fear of potential crimes. 168 Furthermore, a Bill which specifically targeted an individual contravened the concept of equality of treatment before the law. 169 Legislation should apply generally not just to one individual. 170 In commenting on the Community Protection Act 1994 (NSW), Fairall noted that the Act was ‘extraordinary in its particularity’ and claimed that removal of equality of treatment before the law was not justified by necessity, as there were feasible alternatives not given due consideration. 171 Grieg offered an interesting perspective that the particularity of the Victorian Act allowed David to become a ‘political prisoner’ and thus shift attention to the motives of the action against him. 172 The Federation of Community Legal Centres provided perhaps the most detailed analysis and critique of the Victorian Act. One of its major concerns with the Act was proportionality, that is, the length of sentence should relate to the seriousness of the offence, whereas the Act provided for indefinite detention for a crime which had been threatened but not committed. 173 Mead also stressed the need to apply proportionality. 174 Evidence and onus of proof Under the Victorian Act, the onus of proof was effectively reversed, with the accused having to prove that he/she was not dangerous. 175 This was seen by Fairall as contravening the right to a fair hearing and a reduction in the entitlement to liberty. 176 In particular, there were concerns about the requirement in the Act to predict ‘dangerousness’ in order to detain. 177 Not only is ‘dangerousness’ impossible to predict, but according to Wood this terminology was vague and open to subjective interpretation. In addition, it was difficult for the court to decide on the meaning of a number of key phrases, and there were few ground rules for court processes. Other concerns related to the
167 Wood, D. (1990) ‘A one-man dangerous offenders statute: the Community Protection Act 1990’, Melbourne University Law Review, Vol. 17, No. 3, p 505. 168 Williams, C. (1990) ‘Psychopathy, mental illness and preventive detention: issues arising from the David case’, Monash University Law Review, Vol 16, No 2, 161-183. 169 Keon Cohen (1991) Op. Cit. p 69. 170 Fairall, P. (1993) ‘Violent offenders and community protection in Victoria – the Garry David experience’, Criminal Law Journal, Vol. 17, No. 1, 40-54. 171 Ibid. 172 Greig (1993) Op. Cit. 173 Federation of Community Legal Centres (1992) ‘Response to the Government Community Protection (Violent Offenders) Bill, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 179-196. 174 Mead (1991) Op. Cit. 175 Merkel (1992) Op. Cit. 176 Fairall (1995) Op. Cit. 177 Glaser W. and Laster, K (1990) ‘Are the mentally ill being criminalised? Admission of prisoners to psychiatric hospitals before and after the 1986 Mental Health Act (Vic) Australian and New Zealand Journal of Criminology Vol 23 No. 4 230-240
39 difficulty of a prisoner to rebut evidence of dangerous behaviour while in gaol, while before the court (in relation to appeal, parole or other hearings). 178 Greig suggested that while the courts could possibly decide ‘dangerousness’, they should have the power to refer to a special tribunal to consider the ‘sentencing’ or care and treatment options that might be appropriate. 179 Several authors pointed to the difficulty of assessing personality disorder, in addition to predicting dangerousness. In criticizing the legislation, Greig asserted that the legislation focuses on the personality of the individual, rather than the offence. The offence is a perception of what might occur, based on a subjective assessment, which is strongly influenced by political and sociological factors. 180 Mead asserted that the system provided for under the Act was ‘incapable of proof’. 181 Others suggested the assessment of likely offenses is an inappropriate burden to place on psychiatrists, who are required to act as judge and jury.182 Mental health detention is qualitatively different from criminal justice detention. Mental health detention provides for the care and treatment of patients, whereas detention within the criminal justice system involves punishment and retribution for crimes which have been committed. 183 These are fundamentally different approaches. Care, treatment and rehabilitation are unlikely within the criminal justice system.184 Definition of mental illness One of the most controversial aspects of mental health laws is the definition of mental illness. The Australian Law Reform Commission suggested that most Australian States/ Territories have vague, general or circular/tautological definitions of mental illness, and that definitions should be clear enough to lead to treatments which are appropriate. For example the inclusion of senile dementia as a mental illness may lead to inappropriate detention in a mental hospital. 185 Glaser examined the way mental health is defined under the Mental Health Act 1986. 186 Several authors proposed that a ‘common sense’ approach clearly indicated that Garry David could be considered mentally ill. The Law Reform Commission was of the view that instead of incarcerating a person with antisocial personality disorder, that the definition of mental illness be changed to incorporate this disorder. This would provide a rationale for continued detention under more appropriate conditions within the health, rather than the criminal justice system.
178 Wood (1990) p 502. 179 Greig (1993) Op. Cit. 180 Ibid. 181 Mead (1991) Op. Cit. 182 Lucas, W. (1992) ‘A Comment on the Community Protection (Violent Offenders) Bill’, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, p 5. 183 Thomson (1990) Op. Cit. 184 Ibid. 185 Australian Law Reform Commission in “Mental Health Law”, Reform, No. 58, April 1990, pp 77- 82. 186 Glaser (1990) Op. Cit.
40 The Mental Health Act 1986 was designed to significantly improve the provision of mental health services in Victoria, including the processes by which people are diagnosed and certified as mentally ill. However, the Act made it clear that an anti social personality disorder is not to be regarded as mental illness. 187 This was based on a considerable body of scientific psychiatry. Glaser asserted that changing the (Mental Health) law to include personality disorder cannot reconstruct scientific discourse. Assessment of personality is subjective, and personality disorder is not an illness (‘badness is not an illness’). He clarified the difference between Post Traumatic Stress Disorder (PTSD) and mental illness. 188 Williams supports this view noting that including PTSD as a mental illness would be using a fiction to find an easy solution. 189 As indicated in the following pages, the Act was subsequently amended to include people with personality disorder under the broader definition of ‘mental disorder’. The influence of institutional structures on sentencing and treatment options There has been considerable controversy about whether the criminal justice or mental health systems should deal with people who suffer from personality disorders. Options for sentencing and treatment are influenced by the availability and capacity of institutional structures. To date in Australia, the primary responses have been either by the criminal justice system, the mental health system and in some cases the intellectual disability system. Merkel noted that while people with personality disorders should not fall within the criminal justice system, they do not fall within the mental health system. He thus posed the question: where do they belong? 190 The manner in which preventive detention developed in the UK was influenced by the presence of special hospitals in the mental health system. 191 An absence of institutions tends to limit the scope of responses considered. 192 Treatment and rehabilitative responses Several authors suggest that the Garry David problem was addressed too late. People need to receive appropriate treatment, help and assistance from the day they enter gaol. 193 In addition, it was acknowledged that if people with personality disorder did not fit in either criminal justice or mental health systems, then perhaps they required a separate response. This has been addressed in part in Victoria through a number of specialist programs (see Section 6). Mead said that actions to address the case of David started far too late, and argued for rehabilitative detention with an emphasis on better care and supervision. 194
187 Merkel (1992) Op. Cit. p 41. 188 Glaser, W. (2001) ‘Garry David, psychiatry, and the discourse of dangerousness’, Australian and New Zealand Journal of Criminology, Vol. 27, No. 1, 46-49. 189 Williams, C. (1992) ‘Coping with the highly dangerous: issues of principle raised by preventive detention’, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 71-88. 190 Merkel (1992) Op. Cit. 191 UK Home Office and Department of Health (2000b) Op. Cit. 192 Ibid. 193 Merkel (1992) Op. Cit. 194 Mead (1991) Op. Cit.
41 A number of authors considered that some form of rehabilitation should be an option for people with severe personality disorder, and that this had not received sufficient consideration.195 There was a perceived need to design rational preventive and remedial measures. 196 The Victorian Council for Civil Liberties (1992) considered that the very existence of the Community Protection Act diverted attention away from more appropriate options which include rehabilitation. Glaser goes so far as to suggest that a more logical approach to dealing with David would have been to locate him in a home, hundreds of kilometres from anybody, with an aviary and a radio. 197 The Federation of Community Legal Centres indicates that the South Australian Management Assessment Panel provides one way of approaching treatment and rehabilitation for people with severe personality disorder, rather than punitive legislative responses. The Federation considered that the ACT model adapted and extended this model with statutory powers. 198 Williams however, notes that negotiated agreements with offenders are highly questionable, stating that ‘psychopaths are frequently highly manipulative and are anything but constantly rational’. As such, they require a carefully limited system of preventative detention. 199 Mullen et al suggest that the Community Protection (Violent Offenders) Act is a boutique law, which has yet to be applied more widely. ‘In practice, this legislation has failed to impact on the courts who have largely either ignored, or found inapplicable, the provisions of these draconian laws’. 200 Mental Health (Amendment) Act 1996 In a report to the Victorian government, Morton et al recommended that ‘the Mental Health Act be amended, and/or the interpretation of key concepts changed, to clarify that the detention for short periods of clients with personality disorders at risk of suicide or significant self harm is a legitimate use of the Act’. 201 The Mental Health Act 1986 was subsequently amended in 1996. The 1996 amendments were significant, particularly with regard to the coverage of the Act. The new Act included a definition of mental illness and referred to ‘mental disorder’ throughout most of the Act. The Act notes that ‘mental disorder’ includes ‘mental illness’. The Act thus enables the detention of a broader group of people who may not be clinically ‘mentally ill’, as per the agreed classification system, but have a mental disorder that causes them to inflict significant and severe physical harm on themselves. This could include people with personality disorder. The extent to which the Act is interpreted and implemented reportedly varies between different health professionals. The Law Reform Commission notes that ‘mental illness’, which is a sub set of ‘mental disorder’, is defined in
195 Keon Cohen (1992) Op. Cit. 196 Grieg (1993) Op. Cit. 197 Glaser (2001) Op. Cit. 198 Federation of Community Legal Centres (1992) Op. Cit. 199 Williams (1990) Op. Cit. 200 Mullen et al. (2000c) Op. Cit. 201 Morton and Buckingham (1994) Op. Cit. p 70.
42 Section 8(1A) of the Act as a ‘medical condition’, and considers that ‘some people with antisocial or borderline personality disorders, whose behaviour may place others at risk, are not covered.’ 202 Freckleton notes that ‘as yet, there have been few decisions which have explored the meaning of this definition. It has proved surprisingly unproblematic thus far in application.‘ 203 Intellectually Disabled Persons’ Services Act 1986 There has been similar interest in legislative reform in the area of intellectual disability, although this has come somewhat later in the 1990s. In Victoria the provision of services to people with an intellectual disability is governed by the Intellectually Disabled Persons’ Services Act 1986. This Act is not clear about when it is possible to detain and treat a person with an intellectual disability. The Act was established on a platform of rights, equal opportunity and individual consent. 204 Recently there has been a growing awareness that the Act needs to be reviewed, in particular the provisions relating to involuntary care of people with intellectual disability. 205 In 2001 a Review Panel 206 was appointed to review the Victorian Statewide Forensic Service (SFS). Through the Intensive Residential Treatment Program (IRTP), the SFS provides support to people who have an intellectual disability who would otherwise pose a significant risk to themselves and/or the community. SFS services are provided to people on Community Based Orders, on parole, under Guardianship Orders, and people who are Forensic, Voluntary or Security Residents. The Panel’s primary concern was the absence of an appropriate statutory framework within which the State Forensic Services provide support. The statutory framework and provisions for admission, vary according to the legal status of people within SFS care. For a person with an intellectual disability in the criminal justice system, the Sentencing Act 1991, provides for a Justice Plan to be submitted to the court (by Disability Services) which may include the recommendation that the person reside within the SFS IRTP for as long as deemed appropriate by SFS. In summary the SFS Review Panel (Vincent, Chair) determined that there were a number of legislative issues to address. These are summarised below: • The Intellectually Disabled Persons’ Services Act 1986, under which the SFS operates is inadequate in relation to compulsory treatment and care. • No effective independent review mechanism exists • The provisions for admission are spread across a number of Acts and in some cases appear inconsistent
202 Victorian Law Reform Commission (2002) Op. Cit. p 8. 203 Freckleton, I. (1998) ‘Decision making about Involuntary Psychiatric Treatment’, Psychiatry, Psychology and Law, Vol. 5, No 2. 204 Ozanne et al. (1999) Op. Cit. p 316. 205 Tait (2001) Op. Cit. 206 Vincent F. (2000), ‘Report of the Review Panel Appointed to Consider the Operation of the Disability Services Statewide Forensic Service’, September 2001.
43 • The standards under which a facility may operate for the compulsory care of a person are not regulated • The statutory role of the SFS in the context of the broader criminal justice system and disability system is underdeveloped • The statutory framework under which the SFS operates does not identify its principal role as being to rehabilitate people with an intellectual disability who display dangerous antisocial behaviours. 207 The SFS Review Panel made 20 recommendations, covering referral of legislative matters to the Victorian Law Reform Commission, provision for a Senior Clinician within the SFS, establishment of administrative structures for intake and exit, admission criteria, review processes, and community leave. The Intellectual Disability Review Panel (IRDP) generally supported these recommendations, and developed a proposed model for Disability Law Reform. 208 The Victorian Auditor-General also recommended that ‘the review of legislation consider options for strengthening and clarifying the statutory provisions relating to restraint and seclusion, the monitoring role of the Panel, and the scope of reviewable decisions.’ 209 These matters are currently being considered by the Law Reform Commission. The Law Reform Commission has produced a Discussion Paper through which it seeks comments by end September 2002. The Terms of Reference of the Law Reform Commission are shown below. Treatment and Care of Persons with an Intellectual Disability Terms of Reference I. To review existing provisions for the compulsory treatment and care of persons with an intellectual disability who are at risk to themselves and the community; and II. Make recommendations on the development of an appropriate legislative framework for that compulsory treatment and care. The legislative framework should include, amongst things: • the principles and objectives under which compulsory treatment and care would occur; • the process for approving a facility where compulsory treatment and care would occur; • the process of admission to such a facility; • the process for routine and independent review that results in an enforceable decision; • the process that a person can access to initiate a review; • the definition of Restraint and Seclusion, the situations in which it can be applied and relevant reporting requirements; and
207 Ibid. 208 Tait (2001) Op. Cit. 209 Auditor General Victoria (2000) ‘Services for People with an Intellectual Disability’, Melbourne.
44 • whether there is a need for community based compulsory treatment and care. In undertaking this reference, the Commission should have regard, amongst other things, to: • the relevance of the legislative framework to people with other cognitive impairment such as acquired brain injury and dual disability (mental illness and intellectual disability) • the relevance of whether a court order is present or not; and • the process for transfers within the criminal justice system and between the criminal justice system and disability services. In its ‘Discussion Paper’ the Law Reform Commission identifies the following problems with the current legal system: • lack of clear legislative criteria to determine when regulating compulsory care and treatment of people with intellectual disabilities or cognitive impairments is appropriate • limited provision for challenging decisions about compulsory care or treatment of people with intellectual disabilities or cognitive impairments • inconsistencies in the treatment of people falling into different diagnostic categories who are at risk of harming themselves or others under the criminal justice and human services systems • questions about the use of guardianship to deal with compulsory care and treatment issues • reliance on consent which is not true consent, and • conflicting obligations of service providers Guardianship and Administration Act 1986 Care and treatment can be authorised by a guardian appointed under the Guardianship and Administration Act 1986, following an application to the Victorian Civil and Administrative Tribunal. The Law Reform Commission discusses current arrangements and issues. 210 Goonan et al note that mental health legislation is generally discriminatory and does not protect the rights of people with mental illness. They suggest that guardianship legislation might provide the answer: ‘On their reading, careful expansion of provisions of guardianship legislation would provide a remedy.’ 211 However they note that Green asserts that while protection (through detention) of the represented person is a valid guardianship role, protecting others (in the community) from harm, is not. 212
210 Victorian Law Reform Commission (2002) Op. Cit. pp 33, 40, 88. 211 Goonan G. et al. (2000) Op. Cit. p 38. 212 Green D. (1997) ‘Use of public guardianship to impose civil detention on represented persons’, Unpublished manuscript, p 11, cited in Goonan, G. et al. (2000) Op. Cit. p 38.
45 Sentencing Act 1991 The Sentencing Act provides for the detention and treatment of people with mental disorders who have been found guilty of an offence. Where a person is deemed to require treatment a hospital order can be made, however this does not apply to people with intellectual disability unless this is co-occuring. A hospital order is made instead of passing sentence, and a person receives treatment as an involuntary patient. ‘These orders are made sparingly, as the court has no further role to play once the order has been made.’ 213 An alternative is for the court to pass sentence, with the person serving their time within a therapeutic hospital environment. Under the Sentencing Act the court may impose community based orders, and the Act has specific provisions for people with intellectual disabilities who are convicted of offenses. A community based order may require that a person lives in a particular facility, or receive particular care. Often people are required to comply with a ‘justice plan’, which is drawn up by the Department of Human Services. Mullen et al notes that some sentencing provisions for people with severe mental disorders can be problematic. Specifically the Act contains ‘hybrid orders, which enable the courts to impose a sentence and order that this be services either in prison or in a forensic mental services, as dictated by the offender’s prevailing mental state and treatment needs’. 214 This implies that an offender may either be in prison or undergoing treatment depending on their assessed mental state. Mullen says that ‘clinicians are placed regularly by such orders in the ethically untenable position of declaring their patients fit for punishment’. 215 Children and Young Persons Act 1989 The Children’s and Young Persons Act 1989 reflected the government’s intention to close large institutions, and separate young people alleged to have committed criminal offences from those requiring protection and care. Secure Welfare Services was established under the Act. 216 “Legislation and program standard are designed to ensure that only young people at immediate and substantial risk of harm to themselves are admitted, and that the length of placement is minimised”. 217 A review conducted in 1997 found the legislative and policy parameters to be appropriate. 218 Morton et al noted that for young people generally in protective care, there was uncertainty among staff as to how to impose reasonable limits on young people’s behaviour given current interpretations of the Victorian Children and Young Persons Act . . . and there is a lack of practice instructions to guide workers in balancing the duty of care with civil rights.219
213 Victorian Law Reform Commission (2002) Op. Cit. p 29. 214 Mullen et al. (2000c) Op. Cit. p 437. 215 Ibid. 216 Secure Welfare Services (SWS) is provided at two sites, one each for males and females. SWS provides immediate protection from substantial physical, sexual, and emotional abuse, when the broader protection and care network cannot adequately reduce the danger. 217 Victorian Department of Human Services (1997a) ‘Secure Welfare Services Review’, Melbourne. 218 Ibid. 219 Morton and Buckingham (1994) Op. Cit.
46 Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 The Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 was passed by Parliament in 1997, and came into operation in 1998. The Act abolished the system of detaining people at the Governor’s pleasure, thus abolishing an archaic and unjust system, and establishing one that is intended to be fair, and sufficiently flexible to accommodate both therapeutic and treatment needs, while protecting the community from further offending. 220 Lightfoot notes that the formulation of the Act was assisted by the report of the Community Development Committee of the Victorian Parliament, ‘Inquiry into Persons Detained at the Governor’s Pleasure’ 221 and the model Bill prepared by the Model Criminal Code Officers’ Committee. In summary the Act provides for the definition and determination if a person is unfit to stand trial, for the replacement of the common law defence of insanity with the statutory defence of mental impairment, and for new procedures for dealing with people who are unfit to stand trial, or who are found not guilty because of mental impairment. Importantly, the Act ensures that a person cannot be detained simply because they are found unfit to be tried. Rather, a special hearing process is used to test the prosecution’s evidence, and ‘normal’ court processes are used. Where a court imposes a supervision order, it can be framed according to the needs of the defendant. 222 Alcoholics and Drug-dependent Persons Act 1968 This Act provides for the commitment of a person to a treatment centre following a court order and assessment by two medical practitioners and a medical officer in charge of the assessment centre. According to the Law Reform Commission the provisions are rarely used ‘and many of the State Government institutions which had assessment facilities for people affected by alcohol or drugs have been closed down’. 223
4.4 Selected Legislation in other States and Territories
As indicated each State and Territory has different legislation responding to people with high and complex needs. While there appears to be little comparative literature, three papers have been noted to provide some comparisons of State and Territory legislation. Freiburg surveys development in the disposition of mentally disordered offenders since 1976, across State and Territories. 224 Mullen et al considers forensic mental health services in Australia, and provides a comparative table which is reproduced, in part on the following page (Table 4.1).
220 Lightfoot, J. (1998) ‘Striking the balance – Abolition of the Victorian Governor’s Pleasure System’, Psychiatry, Psychology and Law, Vol. 5, No 2, Nov 1998, 265-269. 221 Community Development Committee of the Victorian parliament (1995) ‘Inquiry into Persons Detained at the Governor’s Pleasure’, Victorian Government Printer, October 1995. 222 Lightfoot (1998) Op Cit. p 268. 223 Victorian Law Reform Commission (2002) Op. Cit. 224 Frieburg, A. (1994) Op. Cit.
47 Table 4.1: Summary of Current Australian Mental Health Services – State and Territory Legislation Legislation ACT NSWNT Qld SA Tas Vic WA Sentencing options provide ability to divert following conviction from criminal justice to general mental health service Direct to specialised X X X mental health service PD included in legislative X No X definition of mental defn. limited illness inclusio ns Victims/ families play a X X role in sentencing menta Release X X X l mental impair impair- - ment ment Release of patients X detained by virtue of mental impairment as a Political decision Release of patients X X X detained by virtue of mental impairment as a Legal decision Source: Mullen et al (2000) ‘Forensic Mental Health Services in Australia’, International Journal of Law and Psychiatry, Vol. 23, No. 5-6, p 451.
Freckleton summarises the conditions on which people with a mental disorder can be detained for each State and Territory, referring to each of the various Mental Health Acts. 225
ACT The Mental Health (Treatment and Care) Act 1994, provides for three orders in relation to mental health, including Community Care Orders, Psychiatric Treatment Order and Restriction Order. The Act also provides for the role of the Care Coordinator, and the administration of Orders.
225 Freckleton (1998 ) Op. Cit., Endnote 2, p 261.
48 NSW Somewhat similar to Victoria, NSW enacted the Community Protection Act 1994, applying to a specific individual, Gregory Kable. This allowed Mr Kable to be detained in prison for successive periods of up to 6 months without criminal trial. Fairall discusses the legislation, covering many of the issues debated in Victoria regarding the David case, including equality before the law, and access to common law rights. 226 On appeal to the High Court a majority held the legislation to be invalid.
4.5 United Kingdom
British legislation 227 provides for longer than normal custodial sentences where the original offence has been violent, and where it is necessary to further detain the person to protect the public from serious harm. The effect of this is that a discretionary life sentence can be imposed in cases of violent or sexual offences. Common law precedent also provides for detention of a person with a mental instability, who is considered likely to re-offend and present grave danger to the public if at liberty. Part II of the UK Mental Health Act 1983 provides for compulsory admission to hospital for assessment or treatment. Mental disorder is taken to include psychopathic disorder, as well as other forms of mental illness. For admission to take place, a person with psychopathic disorder needs to be assessed as being likely to benefit from treatment in hospital, before they can be detained. However, lack of facilities and appropriate treatment regimes have resulted in few admissions. 228 This led to a concern that ‘current arrangements for this group are inadequate both to protect the public and to provide the individuals themselves with the high quality services they need’. 229 The Joint Home Office/ Department of Health Working Group put forward two proposals for reforming the way dangerous people with severe personality disorders are managed in the UK.230 The first option built on existing service structures and proposed changes to powers of detention within both the criminal justice and mental health systems. Implementing the provisions of the Crimes Act 1997 in imposing automatic life sentences for those convicted of second serious violent or sexual offences, and extending the availability of discretionary life sentences would lead to higher levels of detention. Although life sentences enabling indeterminate detention are possible under the Act (including where the offender has a serious personality disorder) it may be that offenders with serious personality disorder are considered for detention under civil proceeding as they approach the end of their prison sentence.
226 Fairall (1995) Op. Cit. 227 See Home Office and Department of Health (1999) ‘Managing Dangerous People with severe personality disorder, proposals for policy development’, Annex B Current Legal Provisions, p 27. 228 Ibid. p 10, Clause 13; p 11, Clause 19. 229 Home Office and Department of Health, United Kingdom (2000) Op. Cit. 230 Home Office and Department of Health, United Kingdom (1999) Op. Cit.
49 Dangerous people with serious personality disorders who are not in prison would be managed by health services, whether or not they were likely to benefit from treatment in hospital. 231 “In practice this might require the establishment of specialist secure facilities managed by the health service, or commissioned from the independent sector separate from the existing secure hospital system. These services would need to be focused on the management needs of this group and provide a range of therapeutic approaches that are not currently available in psychiatric hospitals.” 232 The second option saw the creation of a new service and new civil and criminal powers for the detention of dangerous people with severe personality disorder. Following a consultation process the second option was selected, and has commenced implementation. Opposition to the second option was mainly on civil liberty grounds, and related to detention in civil cases. There were concerns that inadequate definition of ‘dangerous’ and inappropriate reliance on historical behaviour as a predictor of future dangerousness would lead to unfair detention. There were also concerns about a lack of specialist services, people being detained in unsuitable conditions, and a lack of knowledge and ability to assess, diagnose, manage and treat such individuals. 233
A White Paper (2000) “Reforming the Mental Health Act, Part II High Risk Patients” sets out in detail the British government’s proposals for improving services to dangerous people with a severe personality disorder. The proposals include: - new statutory powers to detain people with severe personality disorders, including appropriate (DSPD) assessment prior to compulsory detention, further assessment and treatment up to a maximum of 28 days, when the continuing use of compulsory power must be authorized by a new Mental Health Tribunal. People discharged would receive close supervision within the community. - specialist assessment facilities for people who are dangerous and severely personality disordered - power of remand by courts, for assessment and treatment where mental disorder becomes an issue. - sentencing provisions following a specialist assessment for mental disorder, and referral of prisoners for assessment and treatment - development of high security psychiatric hospitals - improvements to the care and treatment of mentally disordered prisoners, including specialist facilities for dangerous severe personality disorder offenders
231 Ibid. p 15, Clause 20. 232 Ibid. p 15, Clause 20. 233 Home Office and Department of Health, United Kingdom (2000) Op. cit. p 10.
50 - development of specialist services based on pilot programs, including treatment programs tailored to the needs of individual (including an evaluation component) which are designed both to manage the consequences of the mental disorder and enable individuals to work towards successful re-integration into the community - collaborative arrangements between the Prison Service and the Health Service, potentially leading to a new ‘third service’ - development of effective community services for individuals discharged into the community, including supervision, accommodation, and risk management arrangements - provisions to protect the rights of individuals detained under compulsory powers - formal establishment of local multi-agency risk panels, or public protection panels to provide expertise and support to police and probation services in the supervision and monitoring of high risk individuals. The Government requires that police and probation services draw up formal risk management strategies. In addition to a legislative framework and the development of services, new national standards of care and treatment of mental disorder have been established through the ‘National Service Framework for Mental Health. 234 The proposed program has a strong research and evaluative component, and has taken into account current research and thinking in relation to severe personality disorder. A collaborative approach has been established with the Netherlands and Canada where ‘considerable thought is being given to taking forward similar evaluative work in respect of their own services.’ 235 The initiative is not without its critics, however, and Mullen argues that the proposals essentially amount to providing for indefinite preventive detention based on the assumption that past offending behaviour is a predictor of future dangerousness. He says that the proposals do not ‘adequately acknowledge that such disorders can be improved, and that the government’s proposals largely ignore the central issue of developing appropriate treatment services, in favour of creating a system for locking up men and women who frighten officials.’ 236
4.6 Legislation in Other Countries
Very few articles examining legislative provisions for people with high and complex needs in other countries have been sourced. The Law Reform Commission makes some reference to the legislative definition of mental illness in Scotland, in the Province of Alberta, Canada, and in New Zealand where compulsory care legislation only covers people who place others at risk. The
234 UK Department of Health (1999) ‘Mental Health National Service Framework’, cited in Home Office and Department of Health, United Kingdom (2000), Op cit. p 7. 235 Home Office and Department of Health, United Kingdom (2000), Op Cit. p 45. 236 Mullen, P. (1999) ‘Dangerous people with severe personality disorder’, British Medical Journal, Editorial, Vol. 319, 30 October, 1146-7.
51 Commission notes other provisions in Northern Ireland, and in the Province of Newfoundland, Canada. One issue of the International Journal of Law and Psychiatry is notable for its international perspectives on forensic mental health systems, across several countries, including Australia, New Zealand, Germany, Austria, Italy, Sweden, The Netherlands, Denmark, Finland, Poland, Russia, Argentina, Brazil, Japan, the United States and Canada. 237
237 Ogloff, J., Roesch, R., and Eaves, D. (2000) ‘International Perspectives on Forensic Mental Health Systems’, International Journal of Law and Psychiatry, Vol. 23, No. 5-6.
52 5 SERVICE SYSTEM ISSUES, BARRIERS AND GAPS, RELEVANT TO EFFECTIVE RESPONSES TO PEOPLE WITH COMPLEX NEEDS
5.1 Introduction
Section 2 shows that while interpretations regarding the definition, conceptualization and degree of complexity of needs vary amongst different disciplines and providers, a number of common behaviours associated with complexity can be described. The literature also shows that there is general agreement that people with behaviours towards the extreme end of the continuum, present the greatest challenge to the policy, legislative and service provision frameworks which currently prescribe responses. For people who require a high level and complexity of service provision, effective responses necessarily involve multiple services spanning across several disciplines, program areas and service organisations. As reflected in the literature, this is particularly the case for people with dual disability, people with mental disorder and/or intellectual disability including those involved in the criminal/juvenile justice systems, or people with personality disorder for whom it is often not clear which services are the most appropriate. The effectiveness of responses is not only affected by the absence or presence of coordinated and collaborative approaches, but by the capacity of individual service organisations to adequately respond. While a number of initiatives have been developed in some departmental areas to more effectively respond to complex need, broad service system, and specific gaps and barriers still exist. A number of authors argue that the process of deinstitutionalisation, commencing in Australia in the 1980s has had a strong influence on the capacity of the service system to adequately respond to people with complex needs (Section 3.2). Many authors have documented barriers to effective responses to people with complex needs. 238 There is remarkable congruence about barriers from amongst the various disciplines and perspectives. This Section commences with a review of literature describing service system gaps and barriers (Section 5.2). It then proceeds to review literature identifying issues, barriers and gaps in various Victorian program areas and services, including mental health (Section 5.3), forensic mental health (Section 5.4), disability services (Section 5.5), child protection (Section 5.6), juvenile justice (5.7), child and adolescent mental health (5.8), housing and homelessness (5.9), and drug treatment services (5.10). Section 6 then reviews a range of constructive responses and required improvements identified in the literature. Key Victorian initiatives are summarised.
238 Keene (2001), Cupitt et al.(1999) Op. cit.
53 5.2 Service System Gaps and Barriers
Keene (2001) notes that ‘ the combination of fragmented service provision in a range of social, health care and criminal justice agencies together with frequent service usage and non compliance by clients, provide major obstacles to addressing the needs of complex clients . . . rendering services wasteful and ineffective and epidemiological information sparse’. 239 Addressing system-wide issues, the US based Taskforce on Dual Disability noted incongruity and incompatibility across a number of dimensions. 240 Barriers identified include: • separate organizational and financial structures/ separate systems 241 • inconsistent administrative rule requirements • differing record keeping and data systems (see also Victorian Department of Human Services Multi Services Client Coordination project) • unrelated performance measurement objectives • uncoordinated funding mechanisms 242 Barriers to service provision lead to increased overhead costs, interference with programmatic innovation and shifting the burden and expenses to other State agencies and the community. 243 Grell states that one of the most pervasive barriers to coordinated services for people with dual disability is the lack of knowledge and training among providers of health, mental health and substance abuse treatment services. 244 Cupitt et al note the failure to understand the need for commitment to longer term interventions, general and broad lack of understanding (of the target group) and of effective ways of ensuring services are responsive, and a lack of adequate identification of the problems. 245 People with complex need are often seen as ‘too hard’ by many providers, encounter barriers to accessing specialist programs, and are shunted between services. In addition to resourcing and skill levels, barriers include record keeping and confidentiality. 246 Drake et al note that access to services has become increasingly restricted as more health care organisations are operating within an exclusive (specialised), rather than an inclusive model of care. They identify policy barriers, program barriers, and clinical barriers and suggest a culture shift is required. 247
239 Keene (2001) Op. Cit. p 28. 240 Oregon Department of Human Services (2000) Op. Cit. 241 See also Cupitt et al. (1999) Op. Cit. 242 See also Keene (2001) Op. Cit. 243 Keene (2001) Op. cit. 244 In Cupitt et al. (1999) Op. cit. 245 Ibid. 246 Ibid. 247 Drake et al. (2001) Op. cit.
54 Keene notes the difficulty of achieving an agreed assessment and/ or ‘diagnosis’ among service providers. Significant professional and philosophical differences between disciplines can result in different (and sometimes opposed) interpretations and orientations towards assessment, causality, treatment and support. 248 Keene summarises specific barriers including time limited models; specialist services operating in silos; bureaucratically defined funding models; poorly defined/ developed cross program linkages; limitations of assessment; and staff skill levels. Frequent use of hospital emergency departments, and jails are not cost effective, and act as a barrier to effective assistance. 249 Somerville and Woogh also note that service provision for people with complex needs is fragmented and uncoordinated, and handicapped by incompatible treatment methods, categorical funding and inadequate staff training. 250 Cupitt notes specialist services have limited understanding of and active involvement with other sectors, including non government and private sector services. 251 A number of authors report that no single method of treatment for any of the various comorbid disorder combinations are proven. Providers rely more on clinical judgements than research evidence. 252 Another system gap is lack of effective multi disciplinary coordination. Barriers to multidisciplinary coordination include: • Lack of sharing information about overlapping populations and shared patients/ clients 253,254 • Lack of common information systems 255 • Lack of principles to underpin shared data, and shared agreed practice models 256 • Insufficient central guidelines 257 • Funding constraints and accountability imperatives (throughput measures) which can result in ‘creaming’ and exclusion of people with complex needs from service provision 258 • Exclusive rather than inclusive criteria and cultures in specialist services misidentification of symptoms259
248 Keene (2001) Op Cit. 249 Ibid. 250 In Keene (2001) Op. Cit. 251 Cupitt et al. (1999) Op Cit. 252 NSW Health Department (2000) ‘The Management of People with a co-existing mental health and substance use disorder’, Discussion paper, Dual Diagnosis project, NSW. 253 Ibid. 254 Brach et al. (1995) in Keene (2001) Op. Cit. 255 Victorian Department of Human Services (1999a) Op. Cit. 256 Keene (2001) Op cit. 257 Brach et al. (1995) in Keene (2001) Op. Cit. 258 Ecumenical Housing Inc. et al. (1999) Op Cit. 259 NSW Department of Health (2000) Op Cit.
55 • Absence of a shared case management approach 260 • Levels of resourcing required 261 Other gaps reported in the literature include: • The conceptualization of complexity of need has only recently occurred at a public policy level.262 • Amount and allocation of resources dedicated to this area 263 • Inappropriate policy, legislative contexts 264 • Lack of sufficient attention to culturally appropriate service provision 265 • Insufficient collaboration among corrections, courts, mental health, substance abuse, social service agencies, housing, employment services 266 • Lack of an agreed model(s), partly due to the wide diversity of needs and debates over appropriate responses. 267 • Lack of quality (longitudinal) research in the area to inform practice 268 • Lack of support by the service system for comprehensive long term case management • Limited training/ understanding amongst professional and clinical staff of the complexities of dual disability – particularly in terms of appropriate cultures, attitude, practices 269
5.3 Mental Health Services
A review of Statewide and specialist mental health services undertaken in 2000 270 made a number of recommendations in relation to service system deficits and limitations. These related to clarifying the role and function of services, definition of target population (affecting access), models of care, effectiveness, consumer participation and other matters. Referring to the diverse origins of the various mental health services the Report noted: “Differences in target populations, clinical approach, training role, research and funding are evident . . . .”271
260 Cupitt et al. (1999) Op Cit. 261 Oregon Department of Human Services (2000) Op. Cit. 262 Ibid. 263 Ibid. 264 Ibid. 265 Ibid. 266 Keene (2001) Op. cit. 267 Cupitt et al. (1999) Op. Cit. 268 Keene (2001) Op. Cit. 269 Cupitt et al. (1999) Op. Cit. 270 Victorian Department of Human Services (2000c) ‘Defining Statewide & Specialist Services’. The Department of Human Services Response and Report of the Review of Statewide & Specialist Mental Health Services. 271 Ibid. p 1.
56 Identified gaps include insufficient residential treatment options, 272 failure of the deinstitutionalisation process to retain certain important features (functional aspects), 273 and specialist programs with criteria which exclude people. Examples where exclusion takes place include self harming behaviour, paraphillias, possible dementia, severe communication deficits, and Asperger’s syndrome (eg. if a person with Asperger’s Syndrome has an IQ of greater than 70, they are ineligible for mental health and intellectual disability services). 274 In relation to implementing a coordinated response to dual diagnosis (mental disorder and substance abuse), Drake et al note that although such an approach is widely advocated, ‘they are rarely offered in routine mental health treatment settings’, and identify a number of barriers. 275 Bennett outlines the considerable challenges faced by the Victorian Dual Disability Service, including lack of psychiatrists within public mental health, especially in rural areas. Lack of time for prolonged assessment, lack of capacity to provide effective case management type support (file review and liaison with a number of service providers, case conferencing, home visits) within public and private systems (as these tasks are not funded by Medicare); lack of collaboration between DisAbility and Mental Health at many levels and lack of support for long term case management approaches; limited training and exposure to the complexities of dual disability; and lack of regional Adolescent Mental Health Service commitment and resources are all key issues.276 In reviewing services for people with severe personality disorders, Spectrum (2001) outlines six main problems with current service planning and provision: • Decisions about allocation and resourcing of individual care packages are sometimes not fully informed by expert clinical opinion from all relevant sectors • Inadequacy of needs analysis and service planning (tends to be crisis driven and reactive) • Insufficient specialist and intensive disability support services within the non- government sector for clients with (extremely) complex needs including insufficient specialist support to existing disability support services within the non-government sector • The limited hours (‘nine to five’) of many disability support services immensely limits their potential usefulness to these clients • Poor cross-sectoral coordination. 277 While the SUMITT Evaluation 278 focused on the clinical performance of the (dual disability) service, it also identified the following:
272 Oregon Department of Human Services (2000) Op. Cit. 273 Green (2002) Op. Cit. 274 Bennett (2000) Op. Cit. 275 Drake et al. (2001) Op. cit. p 473. 276 Bennett (2000) Op. Cit. 277 Spectrum (2001b) Report to Complex Clients working group, April 27th 2001, unpublished. 278 Fox (2000) Op. Cit.
57 • There is a need to strengthen links with Juvenile Justice, Child Protection, and Forensic Services in order to facilitate dual diagnosis clients receiving optimal treatment. • Demand for services exceeds capacity • There are a number of people who are unable to access services from anyone. Access criteria to SUMITT exclude people with depression, anxiety and personality disorder • There is a need to provide a specialised accommodation program ie. long term stable residential rehabilitation services for clients with comorbidity.
5.4 Forensic Mental Health Services
A major gap discussed in the literature is the inadequate and inappropriate treatment of people with complex needs in the criminal justice system. However, the most appropriate way of dealing with offenders with mental illness, personality disorder or an intellectual disability is a contentious issue, 279 and there has been ‘increasing concern about the movement of people with severe psychiatric illnesses into the criminal justice system’. 280 Concerns relate to all stages of interaction including apprehension and interaction with the police, representation before the courts, bail conditions, fitness to plead, sentencing, detention, parole, etc. In Victoria, the Office of the Public Advocate (OPA) notes: “One of OPA’s major concerns is that people with intellectual disabilities, acquired brain injury and mental illnesses are over-represented in the criminal justice system. Too often, the courts and the corrections system are used to manage the behaviour of those more appropriately in need of care and/or treatment.” 281 Ash et al. (1999) note that a lack of services, difficulty accessing those service that do exist, homelessness and high rates of comorbid substance abuse have been proposed as factors contributing to involvement in the criminal justice system. Once a person has been charged, symptoms frequently affect the person’s ability to defend charges, and subsequently cope with imprisonment. Ash et al (1999) refer to several papers which indicate that the presence of major mental illness increases the risk of criminal justice involvement, and this is further increased with alcohol or drug abuse. They argue for specialized services to support patients with a combination of mental illness and substance abuse, as well as special legal services to assist them if and when they face criminal charges. A number of writers have examined the shortcomings of the way the criminal justice system deals with people with high and complex needs.
279 Glaser W. and Deane K. (1999) “Normalisation in an Abnormal World: A study of Prisoners with an Intellectual Disability”, International Journal of Offender Therapy and Comparative Criminology 43 (3). 280 Ash et al. (1999), ‘Self reported Forensic Histories Amongst Patients Admitted to an Acute Psychiatric Unit’, Psychiatry, Psychology and the Law, Vol. 6, No 2. 281 Office of the Public Advocate (2002) ‘Challenges in Community Living’, http://www.publicadvocat
58 Mullen reviewed the relationship between mental disorders and offending behaviours and the management of mentally abnormal offenders in the criminal justice system. He addresses the debate of whether mental disorder is correlated with violent and criminal behaviours. In the late 1990s there was increasing emphasis ‘on the correlations between serious mental disorders and offending behaviours’ by several researchers. Mullen examines evidence in recent literature relating to rates of offending in the mentally disordered, rates of mental disorder among offenders, and community studies. He cites one study which indicated higher levels of violence among people with personality or adjustment disorders, and those with coexisting substance abuse. 282 Mullen also notes several studies which indicate that offender groups contain more individuals with intellectual disability, 283 and other studies associating brain damage with offending behaviour. The coexistence of substance abuse (with mental health and/or disability) increases the association with offending behaviour (Mullen 2001). In a literature review, Lindsay and McDermott (2000) cite Wallace et al. (1998) who concluded that ‘Among those with major mental illness . . . coexisting substance misuse may be the most important contributor to the risk of offending.’ 284 Simpson et al (1999) found that 90 per cent of those people in prison with major mental disorder also had a substance abuse disorder. People with a primary diagnosis of personality disorder or substance abuse frequently do not receive adequate services. There are considerable pressures on forensic services from the courts and correctional and mainstream mental health services to accept those with severe personality disorders. ‘The inclusion of such patients into units and programs designed primarily for the care and treatment of the mentally ill is, however, generally regarded in Australia as inimicable to the interests of both groups’. 285 Mullen et al argue that preventive detention and secure “hospitals” for personality disordered offenders are a political quick fix based on retribution and exclusion. Instead, they suggest programs are required which offer realistic therapy options for a disturbed and needy population.286 Early intervention strategies aimed at reducing the number of damaged personalities would be ‘even better’. Mullen et al notes that most mental health professionals in Australia consider it would be an error to medicalise people with a personality disorder and subject them to detention under the provisions of mental health legislation. Although they suggest there may be an element of self interest here, Mullen et al report that mental health professionals wish to ‘avoid having their expertise and therapeutic roles misappropriated to justify long-term incarceration
282 Monahan J, Steadman, HJ, Applebaum PS, Robbins PC, Mulvey EP, Silver E, Roth, LH, Grisso T. “Developing a clinically useful actuarial tool for assessing violence risk”, British Journal of Psychiatry, 2000; 176: 312-319. See also Policy Research Associates Website, http://www.prainc.com 283 Mullen, P. (2001) Op. Cit. 284 Wallace et al. (1998) ‘Serious criminal offending and mental disorder’, British Journal of Psychiatry, 172, 477-484. 285 Mullen et al. (2000c) Op. cit. p 442. 286 Ibid.
59 on the basis of the supposed presence of difficult to define disorders, believed to increase the probability of future offending’. 287
5.5 Disability Services
Service Issues, Gaps and Barriers Ozanne et al (1999) noted the “apparent absence of effective disability service responses for people with disturbing self destructive and/or dangerous behaviour”, with the result that services were seeking Guardianship Orders for protective intervention as the only option to support individuals. 288 The authors point to the negative impact of problematic behaviours, including disproportionate resource use (time and money), and reduced service delivery effectiveness overall. People with problematic behaviours also experience negative consequences such as rejection by family and carers, loss of liberty and choice, apathy and neglect by staff, and reduced access to other services. The impact of moving to a dispersed community based service provision (from institutions) has increased the difficulty of maintaining consistent standards of treatment and care, suitably qualified and experienced staff, adequate professional supervision, access to external professional support, clear service models and procedures, and adequately supporting people with dual disability. 289 The authors note that the institutional versus community based response has been somewhat passively interpreted as a simple dichotomy, with inadequate community responses the result. Clearer models and cross departmental linkages are required. 290 There is a need for long term intervention and support, as ‘established patterns of severe problematic behaviour do not just disappear’. 291 The review of DisAbility Services’ Criminal Justice Program identifies (inter alia) the following gaps: 292 • Lack of long term accommodation for clients with higher support needs • Lack of specific services for adolescent offenders, particularly sex offenders • Lack of accommodation for female offenders • Inadequate treatment programs and case management within prisons for people with intellectual disabilities • Inadequate links with mental health and specialist dual disability services, where dual disability is indicated • Inadequate statewide management of vacancies and exits and the absence of an interdisciplinary assessment of risk and disability.
287 Ibid. 288 Ozanne et al. (1999) Op. Cit. p 312. 289 See also Green (2002) Op. Cit. 290 Ibid. p 338. 291 Ibid. p 341. 292 Social Equity Consulting Group (2000) Op. Cit.
60 The Victorian Government DisAbility Services High Complex Needs Project, identified support needs of individuals with a disability who have significant and complex behavioural problems. 293 The project was developed in response to a number of factors including increased awareness of higher levels of unmet complex need; the increasing need for on-going case management of some clients; and incremental demand for additional funding to provide intensive support for individual clients with very serious behavioural problems. A separate study revealed that ‘at least 18% of clients receiving DisAbility Services case management had a dual disability (intellectual disability and mental illness), but few were in receipt of mental health services.’ 294 In addition, DisAbility Services notes the concerns expressed by the Office of the Public Advocate, the Ombudsman, the Parole Board, the judiciary and disability advocacy groups. Emerging themes identified in the report include: • lack of shared responsibility across the Department of Human Services’ Divisions and other relevant Departments • concern about gaps in the service system eg. adolescents, those outside an organisation’s legislative mandate, individuals with Acquired Brain Injury and Asperger’s Syndrome. • inadequate service models/ options for accommodation, day programs, therapeutic intervention, recreation and other support needs of individuals with high complex behaviours • concern that unit costing does not reflect the real costs of support • concern that an emphasis on ‘throughput’ detracts from service provision for this group, who commonly require long term support • access and equity issues relating to the existing DisAbility Services’ statewide specialist services • a need to develop the potential role of those committed non government organisations who have demonstrated a willingness to work with individuals with significant behavioural problems • the need for further research, trialing and evaluation of effective models of intervention and support • a need to promote and provide for innovative and flexible responses, which is not encouraged by current funding conditions • discouragement of innovative proposals because of differing requirements of various divisions of DHS and/or other Departments • inadequate training to support staff working with people with high complex needs Toomey focuses on the needs of adolescents with a disability with high and complex needs, and notes the following themes: 295
293 Victorian Department of Human Services (2000b) Op. Cit. 294 Ibid. p 3. 295 Toomey, J. (2000) ‘A Perspective on Adolescents with a Disability’, A report to High Complex Needs Project, DisAbility Services Division, Department of Human Services, p 10.
61 • The current response to young people with high complex needs is regionalised, leading to uncoordinated and ad hoc service development • DisAbility services has not successfully engaged with other divisions or departments to provide a whole of government response • Very few cross programs exist, and there are few mechanisms to support transition between Community Care and DisAbility Services • There are limited residential accommodation options for adolescents, particularly for young people with high complex needs • There are no specialist treatment programs for adolescents with a disability and high complex needs • There is limited specialisation within DisAbility Services to work with high complex needs behaviours • There remains pressure to provide case management on a ‘throughput’ basis, which is inappropriate for young people with high complex needs In Victoria the Office of Public Advocate proposed a major study of the involvement of people with disabilities in all stages of the criminal justice system. 296 The Victorian Office of the Public Advocate highlights the needs of people whose “disabilities give rise to behavioural problems that are not adequately addressed by the mental health system nor the disability services system.” 297 OPA states that their complex needs, which are sometimes exacerbated by substance abuse, are not met, despite substantial allocation of time and resources. OPA considers that better service coordination and possibly legislative reform are required, especially if disabled people with behavioural problems are to be diverted from police custody and imprisonment. Late in 2001, Department of Human Services DisAbility Services undertook a survey of clients with high complex needs. 298 Of the 120 clients identified, 70% had another diagnosis or co-existing secondary diagnosis in addition to intellectual disability. 51% of the client group currently or have had cross – divisional involvement, mainly with Child Protection or Juvenile Justice. About one quarter had been involved with mental health services. Several key points were noted: • Issues with voluntary versus involuntary support packages • Lack of facilities and skilled staff to provide long term support to clients who are not amenable to therapeutic interventions • Lack of access to skilled mental health professionals (and inappropriateness of mental health framework, based on short term intervention for treatable illness, not long term support for psychiatric disorder) • The containment crisis response becomes a long term support model – includes issues of unsustainable costs. Different models are required for different sub-groups, and physical layout of accommodation
296 Office of the Public Advocate (2002) Op. Cit. 297 Office of the Public Advocate (2002) Op. Cit. 298 Victorian Department of Human Services (2001b) Complex clients. Survey undertaken by DisAbility Services.
62 • Difficulties in attracting and keeping support staff • Lack of appropriate day programs/ respite for clients with complex needs • There is a need for the development of cross-divisional strategies to effectively enhance service provision, including community care, drug and alcohol treatment services, forensic services to clients under 18 years of age, and education, training and employment programs.
Criminal Justice Issues Glaser and Deane (1999) suggest that people with intellectual disability are ‘more likely to have their crimes detected and, once apprehended, be ignorant of, or unwilling to exercise their rights, being therefore more likely to confess, plead guilty, be defended by publicly funded lawyers, receive longer sentences, be denied parole, and be victimized in the prison system’. They argue that incarceration of people with an intellectual disability in a prison environment is inappropriate, and that ‘small non-prison-based units offering a range of individualized programs and services, maximize the potential for integration into the community’. Byrnes (1999) examines in detail the disadvantages faced by people with an intellectual disability in the different stages of the criminal justice system. However, she also notes that ‘the law provides certain protections against unjustified loss of liberty and compulsory treatment, whereas in the welfare system, legal safeguards are replaced with professional discretion’. She suggests that there is a reluctance to refer all criminal matters to the police due to the perceived inability of the criminal justice system to deal fairly with people with intellectual disability. In addition she notes that where courts discharge people, they cannot attach conditions such as directions that the person receive appropriate services and accommodation. 299 The over-representation of people with intellectual disabilities, and the significant disadvantages they face in the criminal justice system are also discussed by Fyffe. 300 Glaser and Deane claim that higher levels of offending are partly the result of normalization policies which have led to unrealistic expectations of people with intellectual disabilities, in terms of non offensive behaviours. The criminal justice system appears to be providing few concessions and not excusing offending behaviour by people with intellectual disabilities. 301 Lack of understanding or training by law enforcement officials in dealing with people with intellectual disability has been recognized as a key factor.302 Glaser and Deane (1999) also suggest that the policy of normalization ‘has allowed the human services sector to rid itself of its most difficult clients’. 303
299 Byrnes, L. (1999) ‘People with an Intellectual Disability in the Criminal Justice System’, Disability, Diverse-ability and Legal Change, M Jones and LA Basser Marks (Eds.) Kluwer Law International, Great Britain, 313-326. 300 Fyffe, C. (1999) ‘The Challenge for Community based services: people with intellectual disabilities and problematic behaviours’, Reframing Opportunities for people with an Intellectual Disability, Ozanne, E., Bigby, C., Forbes, S., Glennen, C., Gordon, M., and Fyffe, C. A report funded by the Myer Foundation, School of Social Work, University of Melbourne. 301 Glaser and Deane (1999) Op cit. p 353. 302 Byrnes (1999) Op. Cit. 303 Glaser and Deane (1999) Op. cit.
63 These views are supported by Ozanne et al. The disadvantage to people with an intellectual disability “stems from . . . major skill and reasoning deficits, difficulty understanding their rights, impulsivity, suggestibility, and susceptibility to leading questions, desire to please and poor resilience . . .and they tend to confess overly quickly without advice from independent advisors”. 304 Toomey (2000) provides a similar list of characteristics. 305 In NSW the Law Reform Commission undertook a major review of people with an intellectual disability within the criminal justice system. The report estimated that 12-13% of prisoners had an intellectual disability, compared with 2-3% for the total population. The report concluded that there are major gaps in service provision for people with an intellectual disability in NSW. ‘If these gaps were filled, many people would not enter the criminal justice system in the first place and many others would not reoffend. Key services that are needed include pre- offence programs for people who are at risk of committing offences but with support could be diverted from that path; counselling for offenders and victims; more supervised accommodation and programs for people with an intellectual disability in contact or at risk of contact with the criminal justice system, particularly for people with mild and borderline intellectual disability; and post release or re-integration programs.’ 306 Tait considers that reforms are fundamentally required to ensure that the rights of people with intellectual disability are adequately addressed. Perceived gaps in the service system include: • Issues relating to whether people with intellectual disability are participating in programs voluntarily • People who are unable to communicate their preferences effectively do not have an automatic right to a guardian or advocate • Lack of an external review process of the circumstances where people are detained in locked day programs • Restrictive interventions happen without regard to the consent of an independent decision maker • Managers, rather than clinicians may decide when to use restraint • People living in residential services have no way of asserting their rights • There is a system to hear complaints, but no mechanism to compel a service provider to remedy the situation 307 Tait proposes an overhaul of legislation and the establishment of several tribunals. In May 2001, a Review Panel was established to consider the operation of DisAbility Services’ Statewide Forensic Service (SFS). The Panel’s primary concerns arose “not from the work of the staff at the SFS but from the absence
304 Ozanne et al. (1999) Op Cit. p 313. 305 Toomey (2000) Op. Cit. 306 NSW Law Reform Commission (1996) ‘People with an Intellectual Disability and the Criminal Justice System’, Report No. 80, Sydney. 307 Tait (2001) Op. Cit.
64 of an appropriate statutory framework within which that work occurs”. 308 In addition to making recommendations for legislative reform the Panel made recommendations in relation to internal decision making, admission criteria and processes, service provision, the Intellectual Disability Review Panel, and community access. The issue of compulsory care and treatment of people with an intellectual disability whose behaviour places them or others at risk, was referred to the Law Reform Commission in 2002. The Commission has produced a Discussion Paper which identifies the following problems with the present system: • The rights of people with intellectual disabilities are not adequately protected. Legislation regulating compulsory care and treatment of people who have not been charged with criminal offences deals only with constraint and seclusion. • Although restraint and seclusion are regulated by legislation, there is uncertainty about which practices are covered • Except where the person is charged with or convicted of an offence, or a guardian has been appointed to make decisions on behalf of that person, there is limited opportunity to challenge a decision that a person should be detained or treated without her or his consent • Under the present system, people may be treated as if they have consented to detention or treatment when they lack the capacity to consent or have not had the implications of treatment explained to them. 309
5.6 Child Protection Services
Morton et al found that child protection intervention was insufficient to improve wellbeing without capacity to also address the emotional, behavioural and developmental disturbance associated with severe abuse and neglect. The following service gaps were identified: • Multi-sectoral, multi-disciplinary assessment and case planning • Need to intervene early in the cycle of accumulating harm • Consultation, training and intensive support for kith and kin, carers or staff providing specialist placements • Intensive specialist therapeutic interventions for young people in care who manifest severe emotional and behavioural disturbance • Therapeutic foster care and therapeutic residential group care • Alternative educational programming for children and young people not able to be supported in mainstream schools • Community based intensive therapeutic options as an alternative to custody, or as an enhancement of community based correctional orders, for young
308 Vincent (2001) Op. Cit. 309 Victorian Law Reform Commission (2002) Op. Cit.
65 people with extreme levels of disturbance convicted of violent crimes for drug offences. 310 A review of Secure Welfare Services in 1997 found ‘there is a need to clarify the basis on which a young person subject to criminal charges with some level of protective intervention can be placed in an SWS.’ 311 It notes that resolving a person’s accommodation status is problematic when people are subject to an Interim Accommodation Order. The review noted that there were differing expectations of the Service and in particular in relation to whether it fulfilled a detention/containment or therapeutic role. 312 The Review found that there were limited community based intensive but non secure options for ‘out of control’ young people, and that a more integrated response was required between SWS detention and ‘community’ placements. Improved cooperation between the SWS and protection and care was indicated. Morton et al observe that Secure Welfare Services ‘have insufficient staff and no clear mandate to intervene or to provide consultation’. SWS are short term and crisis based and are not in a position to provide longer term intensive and therapeutic responses. 313 For young people generally in protective care, there was uncertainty among staff as to how to impose reasonable limits on young people’s behaviour given current interpretations of the Victorian Children and Young Persons Act, and there are insufficient practice instructions to guide workers in balancing the duty of care with civil rights. 314 A number of issues associated with the care and management of young people who are clients of Protective Services with challenging behaviour under the High Risk Adolescent Service Quality Improvement Initiative were identified. These include: • Size of units – smaller (eg two residents) may be more ‘normal’, but it may be more difficult to provide a safe and secure environment. Staffing, breadth of expertise and unit costs are affected by size. • Co-placement - can increase negative behavioural synergies • Lack of effective collaboration with support services – mental health, juvenile justice, special education (and the need for robust case management) • Lack of availability of necessary support services – particularly alcohol and drug and mental health services • Lack of specialist services for young people with extreme levels of behavioural disturbance • Inadequate models to govern practice • Resourcing issues
310 Morton et al. (1999) Op. Cit. 311 Ibid. p4. 312 Victorian Department of Human Services (1997a) Op. Cit. 313 Morton et al. (1999) Op. cit. 314 Ibid.
66 • Human resource issues - high staff turnover, staff stress315 Morton et al report that ‘there was considerable consensus that there was a lack of intensive treatment options for young people with extreme levels of disturbance and that intensive interventions frequently started too late . . . ‘ 316 Insufficient and inadequate options have been linked to onset of personality disorder in adult years. 317 The authors also identified a number of service gaps including lack of: • multi-sectoral, multi-disciplinary assessment and case planning • early identification of children and adolescents who have suffered severe abuse and/or neglect, and who manifest high levels of emotional disturbance • consultation, training and support for family, friends and carers • specialist therapeutic outreach services in rural regions • therapeutic residential group care • specialist intensive therapeutic residential or day programs • alternative educational programs • mandatory community-based intensive therapeutic options as an alternative to custody 318
5.7 Juvenile Justice
Morton et al note that ‘current community-based treatment diversion options, except for the MAPPS treatment program for sex offenders, were generally viewed as insufficiently intensive to adequately address the offending behaviour of young people with extreme levels of disturbance’. 319 Other issues identified included: • the long period before cases came to court, and the use of community based orders that were not linked to effective and intensive treatment • perceived reluctance on the part of magistrates to convict and sentence young people if effective mandatory therapeutic options were not available, and a custodial sentence was seen as detrimental. In a national review of juvenile justice services, Keys Young (1997) note that “for young people with mental health problems or those with an intellectual disability there are very few community placements which can deal with both offending behaviour and psychiatric or intellectual disability”. 320 The authors note several difficulties faced by young offenders with mental health problems and intellectual disabilities, including:
315 Success Works (2001) Op. Cit. 316 Morton et al. (1999) Op. Cit. p ix. 317 Ibid. 318 Ibid. p xii. 319 Ibid. p 34. 320 Keys Young (1997) “Juvenile justice services and transition arrangements”, a report to the National Youth Affairs Research Scheme, National Clearinghouse for Youth Studies.
67 • lack of understanding of sentencing, and lack of resources to pay fines • less chance of being given bail due to poverty, lack of employment, lack of family and community support, and unstable living conditions • reluctance by some psychiatric services to take on young people due to a perception that their situation has resulted from drug abuse • lack of mental health and psychiatric services for young people generally, particularly so in rural areas • considerable variability in the quality and comprehensiveness of assessments • staff of juvenile detention centres are not adequately trained to deal with the behaviour of young people with an intellectual disability • lack of inter-departmental cooperation between disability, juvenile justice and mental health • lack of appropriate adolescent residential care for young people with mental health problems upon release from detention • requirement by some services for family involvement. 321 They note “a dearth of Australian research material on disability issues within juvenile detention centres”. Similarly “little appears to be known about the situation of young people with an intellectual disability incarcerated in juvenile detention centres”. 322
5.8 Child and Adolescent Mental Health
There are limited treatment options for young people with personality disorders. While the CAMHS system has a limited number of inpatient beds with a primary goal of providing ‘psychiatric assessment and treatment to young people who display severe emotional disturbance or mental illness where this cannot be managed in community-based settings’, 323 similar issues exist around service access for people with personality disorder as exist in the adult service system. Morton et al note that Spectrum, the statewide personality disorder service, has only a limited role in relation to young people but imply that its role could be expanded to provide support to CAMHS as well as to staff outside mental health services. 324 Intensive Mobile Youth Outreach Services were established in 1998/99 to provide intensive clinical management on an outreach basis for those young people with severe levels of disturbance, complex needs and challenging behaviours whom CAMHS have traditionally found difficult to engage.325 Morton
321 Ibid. p 13. 322 Ibid. p 55. 323 Victorian Department of Human Services (2000d) Op. Cit. 324 Morton et al. (1999) Op. Cit. p 36. 325 Victorian Department of Human Services (2000d) Op. Cit.
68 et al note that this CAMHS service component, while seen as expert, is a limited resource and difficult to access. 326
5.9 Housing and Homelessness
Ecumenical Housing Inc et al (1998) identified ‘external’ barriers to effective service delivery for homeless people with high and complex needs. 327 These included: • Lack of whole of government approach to market failure (housing, labour market) and program failure (generalist and specialist support systems, plus lack of early intervention) • Insufficient housing options including appropriate long term housing options • Lack of multi level linkages between key program areas • Lack of ongoing (long term) maintenance and support • Lack of sufficient mental health, drug and alcohol, intellectual disability and other support services, including lack of appropriate models to cater to complex needs. • Inappropriate cultures and service models to respond to complexity of need • Lack of appropriate mainstream generalist services willing to work with people with challenging behaviours. • Insufficient/ inadequate response to cultural diversity • Lack of an adequate response to Aboriginal and Torres Strait Islander peoples, perceived to have high and complex needs • Inadequate response to people in rural areas The report identifies program barriers (within the SAAP) to effective responses to people with complex needs. These include: • Program management issues – ‘creaming’ lower needs clients (demand exceeds capacity) • The role and focus of SAAP in relation to people with complex needs is not sufficiently clear • Lack of accurate information on prevalence, and agreed definition of high and complex needs • Service models – lack of flexibility and balance to cater for people with complex needs; communal living and duty of care issues; difficulty differentiating eligibility criteria from behavioural issues; insufficient intensive support services; inadequate after hours response; inadequate assertive outreach capacity
326 Morton et al. (1999) Op. Cit. p 37. 327 That is, contextual factors external to the SAAP service system
69 • Skill levels and attitudes among SAAP workers – need for training; accurate comprehensive assessment; inter program linkages; agreed interventions, boundaries and self care • Need for additional program support and resourcing with implications for OH&S; worker client ratios, brokerage funds; appropriate organisational infrastructure, resources and support for working effectively with people with the most challenging behaviours. AHURI (2001) outlines difficulties experienced by people with complex needs in obtaining and maintaining housing, and different strategies for achieving effective linkages to provide services. 328 Other writers report lack of adequate appropriate housing options for people with complex needs. 329,330,331,332 Concerns have recently been expressed about the lack of adequate inpatient discharge planning, which can result in people becoming homeless. 333 There is also a need for additional appropriate supported housing options which can prevent homelessness. 334,335,336 As indicated, several authors make a strong connection between mental illness, dual/multiple diagnosis, challenging behaviours and homelessness. Lamb suggests that mental illness can contribute to loss of accommodation; that living on the streets may increase access to drugs and alcohol, and without support mentally ill people may stop taking their medication. This results in reduced capacity to live independently, obtain income support, and live a healthy lifestyle, and often subsequently leads to bizarre and disruptive behaviour. 337 The Victorian Homelessness Strategy Ministerial Advisory Committee (2001) notes several critical issues for people with serious mental illness: • the inability of homelessness services to provide longer term, more intensive support • lack of discharge planning resulting in people becoming homeless • lack of sufficient long term affordable supported housing (such as the Housing and Support Program) • the need for adequate drug and alcohol services as well as other health and welfare services • perceived difficulty in accessing clinical and psychiatric disability support services
328 AHURI (2001) ‘Effective program linkages: an examination of current knowledge worth a particular emphasis on people with mental illness’ positioning paper’. 329 Oregon Department of Human Services (2000) Op. cit. 330 Green (2002) Op. Cit. 331 AHURI (2001) Op. Cit. 332 Weir, W. (1997) ‘Housing and Supported Accommodation Strategies for people seriously affected by mental illness’, Report to Centre for Mental Health, NSW Health Department. 333 Victorian Government Ministerial Advisory Committee (2001) Op. Cit. p 52. 334 Ibid. 335 Green (2002) Op. Cit. 336 Harvey et al. (2000) Op. Cit. 337 Lamb (2001) Op cit.
70 • lack of psychiatric disability assertive outreach services 338
5.10 Drug Treatment Services
In Victoria, significant developments in the provision of drug treatment services from 1997 onwards, followed the release of the Penington Inquiry in 1996. 339 This was a wide ranging Inquiry, identifying a number of service issues and gaps. The report of the Inquiry paid particular attention to young people, and issues for drug users in contact with the criminal justice system. However, the report did not deal in any detail with people who pose a risk to the community. The report noted service providers’ claims that clients approaching specialist drug and alcohol services were increasingly complex and difficult to manage, and included many with psychiatric illness and severe social problems. It was noted that specialist treatment services lack the capacity to deal effectively with forensic clients. The report identified large gaps in services to support young people with serious drug abuse and related problems. Significant gaps identified included lack of outreach support workers, and lack of residential treatment services. Lack of collaboration between drug and alcohol services and psychiatric services was also noted.
338 Victorian Government Ministerial Advisory Committee (2001) Op. Cit. p 52. 339 Victorian Government Premier’s Advisory Council (1996) Op. Cit.
71 5.11 Gaps and Barriers not Identified by the Literature
While the barriers and gaps identified throughout this section have been described in terms of particular program areas, some people with high and complex needs do not necessarily ‘fit’ within particular areas. As indicated in Section 2, people with high and complex needs frequently encounter one or more of the program areas described above. That is, the literature does not necessarily identify the barriers and gaps experienced by particular groups defined by demography or diagnosis, which can sometimes serve to exclude them from services. 340 These may include people with: • Personality disorder • Asperger’s syndrome • Self harming behaviours, paraphillias, possible dementia and severe communication deficits Children and adolescents with challenging behaviour, Department of Human Services Juvenile Justice and mental health involvement, and people with ABI, each of whom may experience one or more of the foregoing, represent two other high needs groups, for whom specific barriers and gaps are not necessarily identified. The extent to which Aboriginal and Torres Strait Islander people with complex needs and people from culturally and linguistically diverse backgrounds experience additional barriers in the service system has not been researched in this review. It is however an area of importance in planning service system responses.
340 Bennett (2000) Op. Cit.
72 6 TOWARDS IMPROVED RESPONSES
6.1 Introduction
A range of literature proposes improved reposes to people with high and complex needs. Some literature focuses on the need for legislative reform, and this has been covered in part in Section 4. Most significant current proposals to reform Victorian legislation relate to responding to people with intellectual disabilities who are convicted of an offence. Several authors stress the importance of an improved responses which integrate criminal justice and human services responses. In the United Kingdom there has been debate about the proposed reforms to the Mental Health Act, in order to respond to people with dangerous and severe personality disorder. Both these area of reform are briefly covered in Section 6.2. Improved responses are discussed at a system wide level in Section 6.3, including consideration of program coordination and planning, principles, collaborative responses, and the role of specialist services. Section 6.4 reviews literature which discussed improvements at a service level, including principles and practices, and service models. Section 6.5 covers resourcing and staffing issues.
6.2 Legislative context
The need to ensure appropriate legislative provisions for people with high and complex needs is described in Section 4. There is a range of legislation relating to society’s responses to people with an intellectual disability, and mental illness or disorder, and those involved with the criminal justice system. Legislation provides for the treatment and detention of people with mental illness, including reference to assessment and definition. Most jurisdictions have legislation specific to mental illness and disability. There is a range of other relevant legislation covering criminal justice, drugs, guardianship, child protection, HIV AIDS, and other areas. Of particular interest to people with high and complex needs is legislation relating to definition and diagnosis, treatment provisions, and detention provisions. In Victoria and NSW, the concern that mental health legislation did not cover personality disorder was driven by two individual cases. Overseas too, there have been similar cases which have stimulated legislative reform, although many authors view this reform as somewhat reactive. The importance of an approach which integrates human services and criminal justice system responses, including legislative provisions, has been noted. There is widespread agreement that many offenders with mental disorder, and/ or intellectual disability would be better off in community based facilities, compared to prisons, and that there is a need to develop such facilities. Indeed the availability of community options can influence sentencing as suggested by Byrnes (1999). Where there are few options, incarceration may occur by default. Byrne notes some examples of community options, including Pre-
73 Sentence Review Panels in the Illawarra NSW area, and the Lancaster County (Pennsylvania) model. 341 Mullen discusses whether or not there should be separate services for mentally disordered offenders. He advances a number of arguments for a specialist facility to ‘work with mentally disordered offenders who present particularly complex and challenging problems.’ 342 Fyffe emphasizes the need for appropriate service responses to minimize problematic behaviour, including service continuity, staff training and support, professional supervision, organizational processes, and strategies to deal with aggressive behaviours. 343 The Victorian government has responded by establishing in 1998 the Victorian Institute of Forensic Mental Health, mandated by the Mental Health Act 1986, the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 and other legislation, to provide inpatient and community services to mentally ill offenders in Victoria. In addition to service provision, the Institute conducts a range of research. 344 Improved forensic responses were also identified at a national level as part of the Second National Mental Health Plan: • Appropriately secure forensic hospital facilities operated by health providers that are not located in prisons, or co-located with prisons. These hospitals should offer a range of security and treatment options • The need to extend models of forensic mental health service delivery away from a focus on institutional care towards an increasing focus on outpatient and community care • An on-site mental health assessment /liaison service in the courts • A process of systematic mental health assessment for all new receptions into prison • The provision of regular forensic mental health clinics in prison • Forensic mental health outpatient services in the community • Accessible consultation/ liaison service to general mental health programs. 345 Victoria has also established separate facilities for offenders with an intellectual disability. There are two components. Within the disability system, the Intensive Residential Treatment Program (ITRP) provides supported residential accommodation for up to 15 people. The second, within the criminal justice system, commenced in 1990, and provides 22 beds in a maximum security prison. As part of a review of the Victorian Disability Services’ Criminal Justice Program for people with intellectual disability, Bunting et al. examined a range of service
341 Byrnes (2000) Op. Cit. 342 Mullen (2001) Op. Cit. 343 Fyffe (2000) Op. Cit. 344 For example, Glaser, W., and Florio, D. “A community forensic dual disability service: the first ten months” www.forensicare.vic.gov.au/research/research.html 345 Mullen, et al. (2000c) Op. Cit. p 439.
74 models. 346 In particular the need for greater collaboration between criminal justice and human services systems was highlighted. 347 However, it appears to many people that the provision of specific legislation covering people with intellectual disability has fallen behind. In Victoria, matters relating to the Treatment and care of Persons with an Intellectual Disability have been referred to the Victorian Law Reform Commission, and a Discussion Paper has been issued, with responses sought by 30th September 2002. 348 The Discussion Paper explores a number of questions, including: • Who should legislation authorising compulsory care apply to? • Should there be a single process for authorising compulsory care, or a separate process when a person is a risk to others, and another when a person is a risk only to him or herself? • How should risk be assessed? • Should there be a clear list of criteria which must be satisfied before compulsory care is authorised, or should it be a list of criteria to be taken into account? • What forms of compulsory care and treatment should be regulated? • Should any system of regulation authorise compulsory care where the treatment will not directly benefit the person receiving the care? • What sort of care framework and provisions should be required? • Who should be responsible for initiating the compulsory care process; conducting the assessment; for authorising compulsory care and treatment; overseeing compulsory care; and managing compulsory care on a day to day basis? • What review and appeals processes should be in place? • What should be the relationship between the human services system and the criminal justice system? 349 Outcomes from the Commission are expected to more broadly inform the legislative debate, and reform is likely.
United Kingdom In the United Kingdom mental health policy and legislative reform in relation to people with a dangerous and severe personality disorder (DSPD) is proceeding in spite of a recognised lack of knowledge. ‘Findings from previous research studies both nationally and internally have indicated potentially beneficial intervention for the DSPD group, but the results have limited value’. 350 Consequently, this has ‘led to a low evidence base and problems in achieving a professional consensus about service development models’.
346 Social Equity Consulting Group (2000) Op. Cit. 347 NSW Law Reform Commission (1996) Op. Cit. 348 Victorian Law Reform Commission (2002) Op. Cit. 349 Ibid. p 133. 350 UK Government British Home Office and Department of Health (2000a) Reforming the Mental health Act, part II : High Risk Patients, p 29.
75 Nevertheless a number of key areas are being addressed, which are intended to improve responses to people.
6.3 System Based Responses to Improve Services to People with High and Complex Needs
6.3.1 Introduction People with high and complex needs challenge existing service systems. They require a range of services and tailored responses. As shown in Section 2, literature concerned with high and complex needs is found in areas such as homelessness, primary care, disability, dual disability, personality disorder, child protection, mental health and criminal and juvenile justice. In Australia, as well as overseas, governments have established separate policies and programs for most of these areas. Within these, separate programs have been developed for young people and adults. Deinstitutionalisation policies have been accompanied by fragmentation of the service system, both in terms of geographical separation into community based settings, and separation of responses according to specialisation of policy and program areas. 351 Some authors argue that combined with a reduction in funding, this has led to less coordination between services, and in some cases exclusion of people with high and complex needs. Economic rationalism and the imperatives for throughput have discouraged long term treatment and service continuity. 352 Furthermore, for people with high and complex need, responses have been inadequate due to lack of knowledge of aetiology and proven effective treatments. 353 Several authors suggest that people with high and complex needs have been criminalised, and that it has been the criminal justice system which has ‘responded’ in the absence of other appropriate treatment. 354 Understanding and agreeing on the nature of complex needs/behaviours has been a key factor influencing policy and legislation, relevant to people with high and complex needs. For example, the distinction between intellectual disability and mental illness; enhanced understanding of dual diagnosis; and the incorporation of personality disorder within the scope of mental disorder, have all been important stages in the development of improved responses. Change has occurred slowly partly due to the broad range of stakeholders and perspectives, and partly due to lack of evidence to support particular stances or service approaches. Policies to address problem behaviours have been influenced by various professional perspectives (lawyers, criminologists, psychiatrists, mental health administrators, social workers, civil and human rights organizations and
351 Wilson (1999) Op. Cit. 352 Human Rights and Equal Opportunities Commission (1995) Op. Cit. 353 Bradley, A., and Toohey, B. (1999) ‘The Coffs Harbour project: A Violence Prevention Program for Substance Misusing Mentally Ill’, a project funded by the former Commonwealth Department of Human Services and Health, National Drug Crime Prevention Fund Grant and supported by the Northern Sector Mid North Coast Area Health Service. 354 Victorian Law Reform Commission (2002) ‘Treatment and care of Persons with an Intellectual Disability’, Terms of reference, see www.lawreform.vic.gov.au
76 activists, etc), and sometimes by short term and political responses to high profile incidents. Key policy issues are addressed in Section 3 of this review. In summary the literature suggests systemic approaches need to encompass improvements in policy and program frameworks; legislation dealing directly or indirectly with people with high and complex needs; design and resourcing of the relevant government departments (including criminal justice, health, welfare, other); and collaborative and joint responses involving several departments and program areas. 6.3.2 Departmental Program Coordination, and Planning The Social Policy Research Centre notes the need for a coordinated policy framework to support the coordination of approaches, and reconfiguration of organisational structures, linkages and functions. 355 Emery emphasises the importance of eliminating statutory barriers to effective responses, and high level leadership.356 Other writers emphasise the importance of ascertaining incidence to inform program planning and service system reform. 357 Ecumenical Housing Inc et al note the need for a whole of government approach to homeless people with complex needs, including raising the profile of the target group; encouraging collaborative arrangements; local/regional planning and network development; training and education; joint funding and integrated programs and establishing specialist multi-disciplinary teams. 358 Minkoff argues that system level changes are required, that establish formal structures for interprogram collaboration to support the work of front line clinicians. Approaches include contracting integrated managed care organisations; focusing on best practice at a systems level (including planning for services); developing national system level standards; and ensuring adequate availability and flexibility of funding. 359 Cupitt et al propose a change management approach to the service system, for people with dual disabilities, with a high level interdepartmental committee providing monitoring and direction: ‘The evidence suggests that a comprehensive, integrated service system which brings together mental health and drug and alcohol services, working collaboratively with consumers, families and non government organisations, delivers the best outcomes . . . .’ 360 6.3.3 Service System Principles Most texts proposing improved systems and models argue for agreed governing principles. Examples from the literature of governing principles include:
355 Fine, M. (1997) ‘Coordinating Health, Extended Care and Community Support Services: Issues for Policy Makers and Service providers in Australia’, Social Policy Research Centre Discussion Paper No. 80. 356 Emery, B. (2000) ‘Conceptual Frameworks for Co-occuring Disorders’. National Association of State Mental Health Program Directors, National Association of State Alcohol and Drug Abuse Directors, June, Reno, NJ. 357 Keene (2001), Bennett (2000) Op. Cit. 358 Ecumenical Housing Inc. et al. (1999) Op. Cit. 359 Minkoff (1989) Op. Cit. 360 Cupitt, et al. (1999) Op. Cit.
77 • access to all population groups experiencing complex, multiple, chronic and disabling conditions • access to a full range of services in which clients and families have some choice of services suitable to their needs, and potentially reduce the necessity for hospitalization or institutionalisation • coordination and management of care and interventions with transfer of clients to forms of assistance more appropriate to current needs • community based networks using the least restrictive environment • consumer involvement in decisions made • a continuum of care 361 Best practice principles of service delivery for young people have been defined as: • intervene early in the cycle of accumulating harm • provide expert screening and assessment in an agreed cross sectoral format, to plan for appropriate treatment and care. • support staff and carers to deliver effective therapeutic interventions that are backed by research and expert opinion • provide integrated therapeutic interventions on the basis of a shared and holistic, long term perspective (delivered to a person, not a package of behaviours) • provide services in a community setting wherever possible and on an outreach basis if necessary. • ensure a seamless net of services that maximises continuity • provide therapeutic interventions across as many hours in a day as possible and across as many areas of a young person’s life as possible • behavioural expectations should be explicit, realistic and fair • ensure a positive peer culture in all services in which young people are with peers. • consider both short term risk and long term risk when deciding if compulsion is appropriate. 362 6.3.4 Collaborative Approaches People with high and complex needs often require commitment of significant resources, and the level and types of need may influence the form of collaborative responses required. 363 Panels comprising representatives from several program areas have been established in a number of jurisdictions, with the aim of improving responses to people with complex needs, as well as managing associated risks.
361 Victorian Department of Human Services (1999a) Op. Cit. p10. 362 Morton et al. (1999) Op. Cit. 363 Keene (2001) Op. Cit.
78 The United Kingdom established a multi agency approach to risk assessment and management in 1994. These are referred to as Multi Agency Risk Panels, or Public Protection Panels, and comprise police, probation, and health and social services. 364 The role of these Panels has been affirmed and broadened in scope to include people with dangerous and severe personality disorder. In South Australia, the Management Assessment Panel (MAP) has been in operation since 1987, and has served to ensure collaboration between relevant departments and service providers. 365 Similarly in ACT, a Management Assessment Panel was established in 1997 to ensure coordinated interventions across the service system. The ‘Working Together Strategy’ and ‘Multi Service Client Project' provide examples of departmental level initiatives aimed at improved program coordination, and inter sectoral collaboration in Victoria. These include a series of joint initiatives and activities across programs, joint protocols and a quality improvement process. 366 The multi-service client project involved a pilot system of internal referral and coordination to ensure that clients with complex needs receive a range of services in a coordinated and timely manner. Allocation of responsibilities for case coordination, case management and service delivery was a key aspect of the pilot projects in DHS Grampians and Western Regions. 367 Collaboration can occur in a range of ways at a systems level, including through protocols, multi service responses, jointly funded services, co-location, etc. Cross sectoral training, cooperative attitudes, secondary consultation and knowledge sharing and local communication networks and arrangements are associated with good practice for people with complex needs. 368 Responses need to provide cross system access, comprehensive interdisciplinary service delivery and professional credibility between intellectual disability, mental health and other sectors. Links are also required with specialist forensic programs, the police, courts and prisons. 369 The role of the Victorian Department of Human Services in funding innovative responses is also noted. 370 Ridgely et al report on the establishment of regional treatment collaboratives in Maine, USA. These are broad based collaboratives comprising representatives of mental health, public health, substance abuse treatment services, consumers and family members, private practitioners, representative of the criminal justice system, and providers of services to homeless people. Collaborative strategies included development of common terminology, joint treatment planning, collocation of staff, and cross agency training. 371
364 UK Government British Home Office and Department of Health (2000a) Op Cit. 365 South Australia Government Management Assessment Panels. 366 Victorian Department of Human Services (1999a) Op. Cit. 367 Ibid. 368 Ibid. 369 Ozanne et al. (1999) Op. Cit. 370 Mc Donald (1993) Op. Cit. 371 Ridgely, S., Lambert, D., Goodman, A., Chichester, C., and Ralph, R. (1998) ‘Interagency Collaboration in Services for People with Co-Occurring Mental Illness and Substance Use Disorder’, Psychiatric Services, Vol. 49, No. 2, 236-238.
79 An approach to common assessment is an important component to obtaining agreement on service models, treatments and developing collaborative responses to risk management and intervention. In the UK a Risk Assessment, Management and Audit System (RAMAS) was originally developed to provide a common basis for agencies involved in homicides by individuals with mental disorders. 372 The British Government is considering the use of this system as part of its reforms to mental health. The Oregon Department of Human Services Task Force on Dual Diagnosis recommends the establishment of common administrative tools across divisions, offices and programs. 373 Keene emphasises the importance of a multi agency database for policy and planning. 374 The Victorian government also recognises the importance of adequate data and information. This will assist in assessing the impact of service developments targeted at clients of more than one DHS program. 375 6.3.5 Specialist Responses The value of specialist responses as part of an integrated response to people with severe comorbid disorders has been recognised by many authors. 376 Todd however, notes concerns about specialist dual diagnosis services, including a tendency to become exclusive. 377 Treatment models and interventions are described in the literature. A serial model involves treatment in one field, then in another. A parallel model involves treatments side by side, and an integrated model involves concurrent treatment in an integrated approach. The integrated model can be developed as a ‘specialist’ service (eg. Sumitt, VDDS); by protocol/ agreements (eg. SANS with mental health); or by cross program funding (Outreach Victoria, ERMHA). Todd (1997) notes it is not feasible for specialist dual disability services to provide clinical care and treatment for the entire dual disability population. Facilitating links between services, secondary consultation, education and training for staff, and research, monitoring and evaluation are key requirements. 378 Several authors describe the role of specialist services which incorporate the functions of two or more existing program areas, for example specialist dual disability responses. An important role of specialist services is to support and resource generalist providers, thus providing an effective response to people with high and complex needs across a wider geographical area. 379
372 O’Rourke, M. and Hammond, S. (2000) Risk Management: Towards safe sound and supportive service’, Surrey Hampshire Borders NHS Trust. For additional information about RAMAS, see www.ramas.co.uk 373 Oregon Department of Human Services (2000) Op Cit. 374 Keene (2001) Op. Cit. 375 Victorian Department of Human Services (1999c) ‘Managing Clients Initiative Client Volumes Project report, July 1999. 376 Minkoff, K. (1989) ‘An integrated treatment model for dual diagnosis of psychosis and addiction’, Hospital and Community Psychiatry, Vol. 40, No. 10, 1031-1036. 377 Todd (1997) in NSW Health Department (2000) Op. Cit. 378 Ibid. 379 Fox (2000) Op. Cit.
80 Specialist responses, either independent or within existing programs (eg. High Risk Adolescent Quality Improvement Initiative) have been developed in response to complex needs. Examples in Victoria include SUMITT (drug and alcohol and mental health),380 the Victorian Dual Disability Services (intellectual disability and mental health),381 Spectrum (borderline personality disorder) 382 and Forensicare (mental health and criminal justice). 383 Specialist responses can provide a research base, and be set up to resource and provide secondary consultation to other services, as well as direct services to clients. This is important where the field is still seeking to understand and improve responses. Drake et al report that in the USA in recent years there has been a proliferation of dual diagnosis services. ‘Commonly used system-level strategies include building a consensus around the vision for integrated services and then conjointly planning; specifying a model; implementing structural, regulatory and reimbursement changes; establishing contracting mechanisms; defining standards; and funding demonstration programs and training initiatives’. 384 They note that blending mental health and substance abuse funding appears to have been less successful than mental health assuming responsibility, with planning, training and other support provided by the substance abuse agency. The authors note the importance of distinct dual diagnosis leadership in program development. Importantly, mental health clinicians need to acquire new knowledge and skills in relation to substance abuse, and vice versa. The UK is committed to the development of specialist services to supplement exiting prison based services. 385 Specialist, or at least tailored responses are indicated for people with Asperger’s Syndrome. 386
6.4 Service Principles and Practice Approaches
6.4.1 Introduction Improvements required in responding to people with high and complex needs are identified in terms of principles and practice approaches by several authors. 6.4.2 Service Delivery Principles At the service delivery level required improvements relate to governing principles, practice models, approaches and elements, resourcing, governance and management. Examples of service delivery principles have been sourced from service documentation and service and program evaluations and plans.
380 Ibid. 381 Bennett (2000) Op. Cit. 382 Spectrum (2001b) Report to Complex Clients Working Group, April 27th 2001, unpublished. 383 See www.forensicare.vic.gov.au 384 Drake et al. (2001) Op. Cit. p473. 385 UK Government British Home Office and Department of Health (2000a) Op Cit. p 35. 386 Klin and Volkmar (2000) Op. Cit. See also Section 2.8.
81 The SUMITT model of practice is based on seven guiding principles: • engagement of clients • motivation of clients to participate (particularly in relation to drug and alcohol treatment) • comprehensive (holistic) assessment • concomitant treatment (matched to assessed needs) • support during the sub-clinical phase • relapse prevention • ongoing support and development of service linkages 387 SANS/OASIS identifies a number of principles for provision of community based intensive support to people with extreme complex and challenging behaviour: Commitment to the most marginalised in the community. Consistency and continuity: the service does not ‘give up on’ or exclude people. Respect shown to clients Client centred and directed work Establishing and maintaining boundaries for worker and clients Responding to the needs of clients where they are at, and being flexible enough to respond to day to day crises. Acknowledge the role of structural and personal factors Commitment to work towards wellness Acknowledgment of and focus on clients’ strengths and experience, and clients’ desire to improve, and that clients are doing the best they can. Flexibility, including creativity in response to challenging behaviours. Strong links with the community, community resources and other services Quality of service and high professional standards..388 Other important principles are noted by Morton et al in relation to young people with complex needs: • Ensure the young person is established in a safe environment • Provide and support relationships that offer the possibility of secure attachment • Address the aftermath of the trauma, including create a context which is safe, non intrusive and empowering, respect the young person as a survivor, and use techniques that facilitate the integration of awareness
387 Fox (2000) Op. Cit. 388 Thomson Goodall (1999) ‘The Salvation Army Crossroads Network Adult Services: Model of Intensive Support for people who are homeless, and have a range of complex support needs’, The Salvation Army, Melbourne.
82 • Facilitate new learning across all contexts • Provide an appropriate balance between empowerment and limit setting 389 Cupitt identifies values to underpin service development. 390 McDonald and Keene emphasise stabilisation, and an emphasis on maintenance rather than cure as key principles. 391 This has implications for length of support. Participation and decision making by clients (including adolescents) are noted. 392 Underpinning principles of flexible, coordinated, cooperative service delivery are noted by many authors, 393 as are partnerships. 394 A relationship, client centred approach is advocated by several writers, as is a wellness model, based on a holistic, whole of life approach. 395 Mc Donald advocates a ‘do what it takes’ approach, responding to recurring crises and periods of stabilisation. 6.4.3 Practice Approaches The literature indicates that good practice approaches identified for people with complex needs will take the following into account.
Quality of Relationship Between Workers and Clients The importance of establishing a quality relationship is consistently mentioned in the literature. 396 The importance of close personal support, particularly with young people, people with personality disorders and people with high and complex needs experiencing homelessness is highlighted. 397This is associated with the need for high frequency of contact and the quality of the relationship. McDonald states that a housing and support approach for people with high and complex needs ‘is an exercise of relationships and persistence, featuring analytical and creative responses’. 398 It is important that professional staff like clients. 399 Morton and Buckingham describe key (support) worker attributes involving capacity for intensity of support and warmth, requiring involvement in every aspect of day to day life.
389 Morton et al. (1999) Op. Cit. 390 Cupitt et al. (1999) Op. Cit. 391 Mc Donald (1993) Op. Cit. and Keene (2001) Op. Cit. 392 Success Works (2001) Op. Cit. 393 Zufferey, C. (2002) ‘Towards ‘client centred’ Service Provision for Homeless People with High and Complex need’, Parity, Vol 15, No 5., Thomson Goodall Associates (1999) Op. Cit., Emery (2000) Op. Cit. 394 Shepherd, G. (1996) ‘A Redirection in partnership; government and non government services working together’, National Conference on Homelessness, Council to Homeless Persons, Melbourne. 395 Thomson Goodall Associates (1999) Op. Cit. 396 Murray, D. (1998) ‘Ready to make the necessary Connections’, Parity, Vol. 11, No 8, Morton et al. (1999) Op Cit. 397 Murray (1998) Op. Cit., Morton and Buckingham (1994) Op. Cit., Mc Donald. (1993) Op. Cit. 398 Mc Donald (1993) Op. Cit. 399 Mc Donald (2000) Op. Cit.
83 Engagement of Clients Effective engagement with clients is central to forming effective relationships. 400 The engagement process can be lengthy and involve providing help with basic needs, and practical supports, assistance with housing, and slowly building a trusting relationship. 401 Effective engagement will influence outcomes and community reintegration. 402
Long term commitment The capacity to provide continuity in the longer term is emphasised. 403 This often requires persistence and a willingness to accept that assisting recovery is a long and often frustrating process. 404 Intensive support may be required over an extended and undefined timeframe. 405 An interpersonal approach focusing on maintenance, rather than an outcome based approach focusing on a ‘cure’ is supported by several writers. 406 The commitment to engagement and a quality worker – client relationship is linked to the need for a long term commitment to service provision 407 and continuity of service. 408
Holistic Approach Many authors comment on the need for an approach which is concerned with the whole care of a person with complex needs. 409,410 This takes into account the need for housing, 411 support networks, 412 health (eg. RDNS HPP) as well as recreation specific interventions. Burton et al note that socialization and social support is one of the most important models for people with high needs, and the one most frequently missing. The concept of a therapeutic community is part of a holistic approach. 413
6.5 Service Models
6.5.1 Introduction The literature indicates several model components as required for people with complex needs, to be used on an as-needed basis.
400 This is supported by Shepherd (1986) Op. Cit., Sciacca, K. (1991) ‘An Integrated Treatment Approach for Severely Ill Individuals with Substance Disorders’, in New Directions For Mental Health Services, Jossey-Bass, and Morton and Buckingham (1994) Op. Cit. 401 Drake, Osher and Wallach (1991) Op. Cit. 402 Mc Donald (1993), Social Equity Consulting Group (2000) Op. Cit. 403 Mc Donald (2000) Op. Cit. 404 Cupitt et al.(1999) Op. Cit. 405 Mc Donald (1993) Op Cit. 406 Mc Donald (1993) Op. Cit. 407 Keene (2001) Op. Cit., Murray (1998) Op. Cit., Fox (2000) Op. Cit. 408 Shepherd (1996) Op. Cit. 409 Mc Donald (1999) Op. Cit. 410 Ecumenical Housing Inc. et al. (1999) Op. Cit. 411 Dickman (1996) Op. Cit. 412 Keene (2001) Op. Cit. 413 Morton et al. (1999) Op. Cit.
84 The importance of a range of graded residential, community based treatment and support models is linked to the need for comprehensive, accurate assessment, and matching client need with appropriate interventions. 414 Examples include specialised inpatient treatment, short and long term inpatient, residential and community based care, supported housing with outreach support, integrated treatment teams, together with a range of treatment options and interventions. Client interventions include cognitive behavioural training, intensive therapy, relapse prevention training, therapeutic communities, group treatments, simultaneous psychosocial education and substance use education, and ongoing outpatient follow up. Keene proposes a range of psychosocial interventions and maintenance methods. 415 ‘There are clear indications across a range of different disciplines that not only should future models of care (for people with high and complex) be altered, but also that future research should include different measures so that the benefits of the new maintenance or rehabilitative care can be evaluated’. Drake et al note that dual disability services are now emerging as evidence based practice, with a number of critical components tailored to complex needs, including a comprehensive, long term staged approach to recovery; assertive outreach; motivational interventions; and provision of help to clients in acquiring skills. 416 Cupitt suggests that a change management strategy is required to establish an effective dual disability model, together with joint approaches to diagnosis and assessment, case management, treatment, outreach, rehabilitation, withdrawal and on going support across disciplines. 417 Keene argues for a common comprehensive psychosocial perspective and an additional maintenance model of care. In a review of clinical research Drake identifies several elements common to successful intervention including assertive style of engagement, techniques of close monitoring, integration of mental health and substance abuse treatments, comprehensive services, stage-wise treatment, long term perspectives and optimism. 418 A hub and spoke model is cited as good practice.419 This includes a centralised (regional or statewide capacity) with functional relationships with a range of geographical areas and service providers. 6.5.2 Accommodation Many authors stress the importance of appropriate accommodation in any intervention with people with complex needs. They suggest secure, appropriate,
414 Morton and Buckingham (1994) Op. Cit. 415 Keene (2001) Op. Cit. p 174 416 Drake et al. (2001) Op. Cit. 417 Cupitt et al.(1999) Op. Cit. 418 Drake et al. (2001) Op. Cit. 419 Fox (2000) Op. Cit.
85 safe housing is almost always a pre-condition for effective interaction and long term positive outcomes for people with complex needs. 420 A range of supported housing models are required for people seriously affected by mental illness, with the intensity and range of flexible outreach support tailored to the clients needs. Accommodation options include: • inpatient treatment units – open wards, and secure beds • short and long stay, hospital and community based residential units • community based beds including ‘day use’ options • home based residential options • community based shared supported accommodation • community based independent supported accommodation (range of housing types eg. SRS, boarding houses, public, private rental, other) 421 Emery suggests new program housing and support models need to be created. 422 The SUMITT evaluation states that a unified, comprehensive treatment program must have access to beds. 423 Morton and Buckingham state: ‘There is a widely held view that specialist residential services are required for clients with severe or borderline personality disorder’. 424 Morton and Buckingham propose a range of supported housing options including housing attached to hospitals (perimeter, purpose built, on site), and/or dispersed housing in the community. The importance of secure residential programs of different types, 425 and different supported housing models are described. 426 Morton et al argue against residential models for young people wherever possible, proposing instead home based care with intensive therapeutic intervention and support. Weir suggests people with ‘very high support’ needs generally require medium to long term support, 24 hours per day, 7 days per week. High resident to staff ratios are indicated, with clinical and other support provided on-site by specialist mental health staff. 427 In summary, the literature indicates there is a need for a range of models including a crisis intervention/ response capacity, the provision of interim
420 Mc Donald (1993) Op Cit., Weir, W. (1997) ‘Housing and Supported Accommodation Strategies for people seriously affected by mental illness’, Report to Centre for Mental Health, NSW Health Department. AHURI (2001) Op. Cit., Shepherd (1996) Op. Cit., Morton et al. (1999) Op. Cit. 421 Morton and Buckingham (1994) Op. Cit. 422 Emery (2000) Op. Cit. 423 Fox (2000) Op. Cit. 424 Morton and Buckingham (1994) Op. Cit. 425 Social Equity Consulting Group (2000) Op. Cit. 426 AHURI (2001) Op. Cit., Dickman (1996) Op. Cit. 427 Weir (1997) Op. Cit.
86 support, intensive long term therapy,428 and on going maintenance and stabilisation in the long term. 429 6.5.3 Outreach A number of writers describe the effectiveness of outreach models including ‘assertive outreach’, and ‘detached outreach support’ to people with complex needs, 430 particularly for people experiencing homelessness. Descriptions of outreach are also provided in documentation of mental health outreach programs.431 Outreach models, providing support to people in a variety of accommodation settings in the community, with protocols with mental health services enabling hospitalisation for specific periods as needed. 432 Advantages of the outreach approach include the capacity to ‘track’ people across service boundaries and geographical locations (prison, hospital, community sector, etc.) 433 The outreach model is characterised by flexibility to respond to multiple needs. 434 Other advantages include the capacity to vary the level of support provided according to need. 435 Outreach is less resource intensive than residential models, with demonstrated reduced costs to the community. 436 6.5.4 Service Delivery Components
Crisis Intervention • need for regional and centralised crisis service responses to support services 437 • role of crisis services in an ongoing (out of hours) and back up capacity 438
Assessment • agreed diagnostic assessment approaches 439
Clinical interventions Examples include:
428 Morton et al. (1999) Op. Cit. 429 Morton et al. (1999) Op. Cit. 430 Mc Donald (1993) Op. Cit.; Jesuit Social Services (2001) ‘Connexions’ Victorian Public Health Awards for Excellence and Innovation; Olivieri (2000) Op. Cit.; Victorian Government Department of Human Services (1997b) ‘Disability Homeless Outreach and referral Service’ (DHORS); Morton and Buckingham (1994); Drake et al. (2001) Op Cit. 431 North Western Health (1997) ‘Waratah Area Homeless Outreach Psychiatric Service (WAHOPS): Program Description’. Inner West Area Mental Health Service. 432 Thomson Goodall (1999) Op. Cit. 433 Mc Donald (1993) Op. Cit. 434 Shepherd (1996) Op. Cit. 435 Thomson Goodall Associates (1999) Op. Cit. 436 Mc Donald (1993) Op. Cit.,Fox (2000) Op. Cit. 437 Morton and Buckingham (1994) Op. Cit. 438 Mc Donald (1993) Op. Cit. 439 Cupitt et al. (1999) Op. Cit., Bennett (2000) Op. Cit.
87 • utilising traditional treatment approaches within existing specialty areas (mental health, drug and alcohol, other) in the context of a coordinated approach 440 • range of (other) service delivery approaches, and treatment modalities including: - individual counselling 441 - group work – self help; therapy 442 - individual therapy/ psychotherapy 443 - cognitive behavioural models, eg. dialectical behaviour therapy 444, behaviour modification approaches 445 - Object relations models 446 - Self psychology 447 - motivational interviewing 448
Case Management • matching needs with service provision, including referral processes 449 • clarifying agreed goals, and shared vision for each client450 • case conferencing with other providers 451 • case coordination, liaison, monitoring 452 Several authors highlight the importance of improving linkages between existing services; through joint assessments; co-case management, cross sector collaboration, co-location, and protocol development.. 453 Effective links are central to successful models for people with complex needs. 454
440 Sciacca, K. (1991) ‘An Integrated Treatment Approach for Severely Ill Individuals with Substance Disorders’, in New Directions For Mental Health Services, Jossey-Bass (sourced from www.psychosocial.com/dualdx/). 441 Lipsey et al. (2000) Op. Cit. 442 Morton and Buckingham (1994) Op Cit., Osher and Kofoed (1989) Op. Cit. 443 Ibid. 444 Linehan (1993) Op. Cit. 445 Osher and Kofoed (1989) Op. Cit. 446 Kernberg (1984) in Morton and Buckingham (1994) Op. Cit. 447 Meares (1992) in Morton and Buckingham (1994) Op. Cit. 448 Osher and Kofoed (1989) Op. Cit. 449 Bennett (2000) Op. Cit. 450 Olivieri, R. (2000) ‘Towards effective intersectoral action; understanding how to collaborate to achieve better outcomes for people with high and complex needs’, Homelessness in the 21st Century: working together for change. South Australian Department of Human Services, Adelaide, 92-98. 451 Cupitt et al. (1999) Op. Cit. 452 Shepherd (1996) , Victorian Government Department of Human Services (1997b) Op. Cit. 453 Keene (2001) Op. Cit. 454 Morton et al. (1999) Op. Cit.
88 Psychosocial Interventions • targeted psychosocial programs 455 • interpersonal skills development 456 • independent living skills 457 • vocational training 458 • education 459 • creative arts, activities 460 • recreation 461 • mentor programs 462 • structured activities 463
On going Support and Case Management • maintenance, continuity 464 For people with high and complex needs, the aim of maintenance management is to reduce the physical, psychological and social harm, limit damage to self and others, and prevent deterioration. In this sense it is qualitatively different from therapy or rehabilitation, but can be an addition to change oriented approaches. The maintenance concept is consistent with the view that long term support is essential for people with complex needs. 465 Keene provides a list of maintenance methods, including motivational strategies, cognitive and behavioural methods, relaxation, stress management, anger control, client centered counseling methods, skills training, social support, practical help and life skills training. 466 6.5.5 Functions Within the Service System In addition to direct service delivery, effective service models have critical functions within the broader service system aiming to support and develop good practice in generalist and other services.
455 Morton and Buckingham (1994) Op. Cit. 456 Lipsey et al. (2000) , Drake et al. (2001) Op. Cit. 457 Drake et al. (2001) Op. Cit. 458 Jesuit Social Services (2001) Op. Cit.; Klin and Volkmar (2000) 459 Sciacca (1991) Op. Cit. 460 Murray (1998) Op. Cit. 461 Mc Donald (1993) , Victorian Government Department of Human Services (1997b) Op. Cit. 462 Social Equity Consulting Group (2000) Op. Cit. 463 Osher and Kofoed (1989) Op. Cit. 464 Mc Donald (1993) Op Cit., Keene (2001) Op. Cit. 465 Mc Donald (1993) Op. Cit. 466 Keene (2001) Op. Cit.
89 Specialist Input to Assessment The role of specialist input to assessment of people with high and complex needs is noted by a number of writers. 467 Melishyn (1996) and Room (1997),468 emphasise the need for improved identification and assessment, and follow up mechanisms and practices. They advocate comprehensive assessments and screening tools. Bennett describes a multi-disciplinary comprehensive assessment that can take between one to three visits, followed by case conferencing with relevant parties. Keene emphasises the importance of biopsychosocial assessment. This approach addresses individual needs and abilities within social contexts and constraints. Rather than focusing on individual pathology it focuses on the range of interacting psychological and social factors, to inform an appropriate intervention plan and holistic approach. 469 Other writers note the importance of an accurate clinical assessment to identify relevant aetilogical factors as different diagnoses will have significant treatment/ intervention implications. 470 Emery advocates the development of common assessment tools/ framework across disciplines for people with high and complex needs, with clinical competence at all (specialist) service entry points. The importance of diagnostic clarity and terminology is highlighted 471 as is a multi-disciplinary assessment which enables transfer of skills from specialist providers to a broader staffing base. 472
Coordination Systems coordination and liaison, input to coordinated care strategies (based on accurate assessment) and facilitation of cooperative inter service arrangements are key resourcing functions. 473
Secondary Consultation Secondary consultation is a key function, to be provided in relation to specific clients, and to service planning, to assist providers to increase skill levels, and enhance service effectiveness. 474
Education and Training A number of specialist services incorporate education and training as a key resource function. 475 The importance of dedicated, funded positions for
467 Bennett (2000) Op Cit., Drake et al. (2001) Op Cit., Osher and Kofoed (1989) , Op. Cit. Olivieri (2000) Op. Cit. 468 In NSW Health Department (2000) Op. Cit. 469 Keene (2001) Op. Cit. 470 Bennett (2000) Op. Cit. 471 Sciacca (1991) Op. Cit. 472 Bennett (2000) Op. Cit. 473 Fox (2000) Op. Cit., Bennett (2000) Op. Cit. 474 Ibid. 475 Ibid.
90 education and training is supported. 476 One approach is to provide formal, structured training with basic, intermediate and advanced training offered. 477 Other training modes include contracted workshops for service provides and clinicians, and academic (ie tertiary) training. Training can be in skill development, raising knowledge and awareness and use of information for policy development.
Network Development Working to enhance the effectiveness of service systems is a key role of some specialist services. 478 This occurs through developing and disseminating best practice wisdom and facilitating cooperative inter service arrangements and networks. 479
Research and Evaluation Several writers describe research, evaluation and quality improvement activities. 480 These include developing and testing new models, demonstrating outcomes, and designing mechanisms for monitoring. 481The importance of research to inform policy development is noted. Identification of client outcomes for people with complex needs is an area for development. 482
Service Development Cupitt outlines a change management strategy designed to achieve an enhanced service system. The VDDS and SUMITT models also aim for changes within existing services, at organisational and practice levels.
6.6 Resourcing and Staffing
6.6.1 Introduction A number of articles identify the need for adequate resourcing of programs for people with high and complex needs, particularly the need for adequate, appropriate staffing and specialist skill levels. The importance of community and other support for community based initiatives is highlighted. 6.6.2 Resourcing Funding for different residential options, supported housing, outreach, therapeutic communities, intensive therapy, and psychosocial opportunities is noted. 483
476 Morton and Buckingham (1994) Op. Cit., Emery (2000) Op. Cit., Keene (2001) Op. Cit. 477 Morton and Buckingham (1994) Op. Cit. 478 Bennett (2000) Op. Cit., Fox. (2000) Op. Cit. 479 Bennett (2000) Op Cit. 480 Keene (2001), Bennett (2000), Social Equity Consulting Group (2000), Fox (2000) Op. Cit. 481 Morton and Buckingham (1994), Fox (2000) Op. Cit. 482 Keene (2001) Op. Cit. 483 Morton and Buckingham (1994) Op. Cit., Morton et al. (1999) Op. Cit.
91 Funding for adequate staffing (worker – client ratios) and flexible funding are associated with good practice models. 484 Multiple funding sources, including funding incentives which are aligned with outcomes, are required. The need for adequate management resources, information technology resources, and adequate resources for backfill in order that staff can undertake appropriate training and professional development are other important considerations. 485 Innovative local level initiatives include combining funding to target high needs. 486 6.6.3 Staffing Several authors note the importance of ensuring services for people with complex needs are staffed by multi-disciplinary clinical and professional staff with appropriate skills. Morton et al suggest that generic skills are not enough to provide a service to young people in the highest category of complexity. Therapeutic intervention must be expertly delivered to be effective. Strategies are required to manage staff burnout, difficult staff experiences, and preventing troubled relationships between staff and clients (especially young people). 487 The capacity to provide training and support is another staffing requirement.488 The importance of management systems and staff support structures, peer consultation, professional development and clinical supervision, are critical factors associated with effective models. 489 Todd notes the importance of collaborative partnerships, a skilled workforce, agreed frameworks, and service delivery guidelines. 490 Minkoff notes the importance of an integrated conceptual framework, standards of care, service quality and outcome measures, practice guidelines, competencies and training. 491 6.6.4 Stakeholder Participation Several authors describe the importance of reference groups, and community consultation committees, comprising key stakeholders, clear reporting relationships and the development and resourcing of local service system networks 492 to work effectively with people with high and complex needs. Other key organisational factors identified in the literature relate to: • strong program management (creative program, policies, plans, funds, acquittal processes and outcome measures) 493
484 Mc Donald (1993) Op. Cit. 485 Fox (2000) Op. Cit. 486 Emery (2000) Op. Cit. 487 Morton et al. (1999) Op. Cit. 488 McDonald (1993), Morton and Buckingham (1994) Op. Cit. 489 Morton and Buckingham (1994), Mc Donald (1993), Fox (2000) Op. Cit. 490 NSW Health Department (2000) Op. Cit. 491 Minkoff (1989) Op. Cit. 492 Fox (2000) Op Cit., Bennett (2000) Op. Cit., and Victorian Government Department of Human Services (1997b) Op. Cit. 493 Ecumenical Housing Inc et al. (1999) Op. Cit.
92 • appropriate service management infrastructures and resources (human, financial, physical) 494 • appropriate service models, role and focus for the target group 495 • staff support and development 496 • capacity for research and policy input 497 Good practice at an organisational level requires strong leadership, governance and management; appropriate staffing and skill levels (adequately trained staff),498 service models, effective service system relationships, adequate documentation and accountability systems, flexible funding, reflective practice and quality improvement processes. 499 Concluding Comment Detailed descriptions of some models are available in the literature. Examples include: • Child protection for young people with high and complex needs 500 • Spectrum (for people with personality disorder) 501 • Victorian Dual Disability Service (for people with mental health and intellectual disability) 502 • SUMITT (for people with mental health and substance abuse) 503 • SANS, CHAST, DHORS, WAHOPS, other (for people with high and complex needs and homelessness) 504 • Forensicare (for people with mental illness who have been convicted of an offence)
494 Ibid. 495 Ibid. 496 Mc Donald (1993) Op. Cit. 497 Morton and Buckingham (1994) Op. Cit. 498 Emery (2000) Op. Cit. 499 Morton et al. (1999) Op. Cit., Success Works (2001) Op. Cit. 500 Morton et al. (1999) Op. Cit. 501 Morton and Buckingham (1994) Op. Cit. 502 Bennett (2000) Op. Cit. 503 Fox (2000) Op. Cit. 504 Thomson Goodall (1999), Zufferey (2002), North Western Health (1997), Olivieri (2000), Shepherd (1996) Op. Cit.
93
Predominant sectors, Primary presenting Examples of Models Key factors or service issue programs associated with classifications success Child Protection Young people with High Risk Adolescent Intensive case serious personal or Service Quality Management Service community risk issues Improvement Initiative One to one home based Criminal behaviour Residential models care Joined up initiatives Brokerage funds Mental health and Dual disability (mental Victorian Dual Disability Assessment Disability illness , intellectual Service, Secondary consultation disability) Sector change
Training and development Mental health and drug Mental disorder and Proliferation of US Integrated models; hub treatment substance abuse models and spoke model SUMITT; Galilee Mental health Personality disorder Spectrum Residential; CBT Forensic psychiatry Mental illness and Forensicare Residential involvement with Community Orders criminal justice system Disability and criminal Intellectual disability Statewide Forensic Intensive Residential justice system and involvement with Service Treatment Program criminal justice system CAMHS Adolescents with IMYOPS Outreach team mental health
94
Predominant sectors, Primary presenting Examples of Models Key factors or service issue programs associated with classifications success Homelessness and Challenging behaviour SANS Detached outreach complex needs Complex needs and CHAST (SA) support – access to chronic homelessness Outreach Victoria housing Intensive Support Protocols services (incl. IYSS) Key worker model Disability Acquired Brain Injury ARBIAS Secondary consultation Asperger’s Syndrome ABI services (eg. MCM) Outreach Mental health and Homeless with mental HOPS (WAHOPS, Specialist outreach homelessness illness CHOPS, etc.) ERMA Health and Homeless with primary RDNS HPP Outreach, primary homelessness health issues health care, advocacy Disability and Homeless and disability DHORS Outreach, coordination homelessness issues Cross sector Complex behaviours Management Coordination Assessment Panel Community Based Orders Drug treatment and Substance misuse, YSAS Centre based, and adolescents with high complex needs outreach. Residential; needs withdrawal. counselling drug treatment Mental health and Violence and complex Coff’s Harbour Project Collaboration police behaviours Aged Care, Mental Homeless and at risk Community Assertive outreach, Health Connections Program flexible funding
95 Ash, D., Gallety, C., Kinneally, J., and Braben, P. (1999), ‘Self reported Forensic Histories Amongst Patients Admitted to an Acute Psychiatric Unit’, Psychiatry, Psychology and the Law, Vol. 6, No 2, 197-202. Australian Housing and Urban Research Institute (2001) ‘Effective program linkages: an examination of current knowledge worth a particular emphasis on people with mental illness’ positioning paper’ Australian Institute of Criminology. Australian Law Reform Commission (1990) ‘Mental Health Law’, Reform, No. 58, April 1990, pp 77-82. Bath, H. (1998) ‘Missing the mark: Contemporary Out of Home Care Services for Young People with Intensive Support Needs’, Association of Children’s Welfare Agencies and the Child and Family Welfare Association of Australia. Bennett, C. (2000) ‘The Victorian Dual Disability Service’, Australasian Psychiatry, Vol. 8, No. 3, 238-242. Bradley, A., and Toohey, B. (1999) ‘The Coffs Harbour project: A Violence Prevention Program for Substance Misusing Mentally Ill’, a project funded by the former Commonwealth Department of Human Services and Health, National Drug Crime Prevention Fund Grant and supported by the Northern Sector Mid North Coast Area Health Service. Burton, L., Cox, A., Fleisher-Bend, M. (2001) ‘Cross training for dual disorders. A comprehensive guide to co-occuring substance use and psychiatric disorders’, Vantage Press, NY. Byrnes, L. (1999) ‘People with an Intellectual Disability in the Criminal Justice System’, Disability, Diverse-ability and Legal Change, M Jones and L A Basser Marks (Eds.) Kluwer Law International, Great Britain, 313-326. Commonwealth Advisory Committee on Homelessness (2001) ‘Working Towards a National Homelessness Strategy’, Commonwealth of Australia, Canberra. Commonwealth Department of Health and Aged Care, Mental Health Branch (1998) National Mental Health Report 1997. Fifth Annual Report. Changes in Australia’s Mental Health Services under the National Mental Health Strategy, Canberra. Commonwealth Department of Health and Aged Care, Mental Health Branch (1999) Mental Health Promotion and Prevention National Action Plan, Canberra. Cupitt, L., Morgan, E., Chalkley, M. (1999) ‘Dual diagnosis: Stopping the Merry go round’, ACT Department of Health and Community Care, Canberra. Davis, C., Martin, G., Kosky, R., and O’Hanlon A. (2000) Early intervention in the mental health of young people: A literature review’, The Australian Early Intervention Network for Mental Health in Young People, Flinders University. Degenhardt, L. (2000) ‘Interventions for people with alcohol use disorders and an intellectual disability: A review of the literature’, Journal of Intellectual & Developmental Disability, Vol. 25, No. 2, 135-146.
96 Dickman, S. (1996) ‘Closing the Gaps. Housing and support for people with Dual Disabilities’, VCOSS, Victoria. Drake, R.E., Essock, S.M., et al (2001) ‘Implementing Dual Diagnosis Services for Clients with severe Mental Illness’. Psychiatric Services, Vol. 52, No. 4. Drake, R.E., Osher, F.C., and Wallach, M.A (1991) ‘Homelessness and Dual diagnosis’, American Psychologist, Vol. 46, No 11, 1149-1158. (Sourced from www.psychosocial.com/dualx/) Dudley, J., Ahlgrim-Delzell, L., and Calhoun, M. (1999) ‘Diverse diagnostic and behavioural patterns amongst people with a dual diagnosis’, Journal of Intellectual Disability Research, Vol. 43, Part 2, 70-79. Ecumenical Housing Inc and Thomson Goodall Associates (1999) ‘Appropriate responses for homeless people whose needs require a high level and complexity of service provision’. A Report for the Department of Family & Community Services, Canberra. Emery, B. (2000) ‘Conceptual Frameworks for Co-occuring Disorders’. National Association of State Mental Health Program Directors, National Association of State Alcohol and Drug Abuse Directors, June, Reno, NJ. Fairall, P. (1993) ‘Violent offenders and community protection in Victoria – the Garry David experience’, Criminal Law Journal, Vol. 17, No. 1, 40-54. Fairall, P. (1995) ‘Imprisonment without conviction in NSW.: Kable v Director of Public Prosecutions’, Sydney Law Review, Vol 17, No 4, 573-580. Federation of Community Legal centres (1992) ‘Response to the Government Community Protection (Violent Offenders) Bill, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 179-196. Fine, M. (1997) ‘Coordinating Health, Extended Care and Community Support Services: Issues for Policy Makers and Service providers in Australia’, Social Policy Research Centre Discussion Paper No. 80. Fox, A. (2000) ‘Final Report on the SUMITT Evaluation’, June 2000. Freckleton, I. (1998) ‘Decision making about Involuntary Psychiatric Treatment’, Psychiatry, Psychology and Law, Vol. 5, No 2. Frieburg, A. (1994) ‘The disposition of mentally disordered offenders in Australia: ‘out of mind, out of sight’ revisited’, Psychiatry, Psychology and the Law, No. 2, 97-118. Fyffe, C. ‘The Challenge for Community based services: people with intellectual disabilities and problematic behaviours’, in Ozanne, E., Bigby, C., Forbes, S., Glennen, C., Gordon, M., and Fyffe, C. (1999), ‘Reframing Opportunities for people with an Intellectual Disability’, A report funded by the Myer Foundation, School of Social Work, University of Melbourne. Gerull, S. and Lucas, W. (Eds) (1991) ‘Serious Violent Offenders: sentencing, psychiatry and law reform’, Proceedings of a Conference held 29-31 October 1991, Melbourne, Australian Institute of Criminology. (see www.aic.gov.au/publications/proceedings)
97 Glaser W., Laster, K (1990) ‘Are the mentally ill being criminalised? Admission of prisoners to psychiatric hospitals before and after the 1986 Mental Health Act (Vic) Australian and New Zealand Journal of Criminology Vol 23 No. 4, 230-240. Glaser W. and Deane K. (1999) ‘Normalisation in an Abnormal World: A study of Prisoners with an Intellectual Disability’, International Journal of Offender Therapy and Comparative Criminology, Vol. 43, No 3, 338-356.. Glaser, W. (2001) ‘Garry David, psychiatry, and the discourse of dangerousness’, Australian and New Zealand Journal of Criminology, Vol. 27, No. 1, 46-49. Glaser, W., and Florio, D. “A community forensic dual disability service: the first ten months” www.forensicare.vic.gov.au/research/research.html Goonan, G., Healy, B., Moynihan, P. (2000) ‘The Death of the Subject. Human Rights, Due Process, and Psychiatry’, International Journal of Law and Psychiatry, Vol. 23, No. 1. 23-41. Gray, D. ‘The High Functioning Autism Project’. Green, D. (2002) ‘Homelessness and mental illness’, New Paradigm, April, pp 3-9. Grieg, D. (1991) ‘The Politics of Dangerousness’, in ‘Serious violent offenders: sentencing, psychiatry and law reform’, Proceedings of Conference, Australian Institute of Criminology, October 1991, 47-66. Hage, M. (1989) ‘People with mental disorder and homeless’, Council to Homeless Persons, Victoria. Harvey, D., Hunter, E. and Whiteside, M. (2000) ‘The accommodation and support needs of people with a mental illness: A process and framework for action’, Australian Social Work, Vol. 53, No. 4, 7-14. Hermann, H., McGorry, P., Bennett, P., van Riel, R., Wellington, P., McKenzie, D. and Singh, B. (1988) ‘Homeless people with Severe Mental Disorders in Inner Melbourne’, Council to Homeless Persons. Hobbs, C., Newton, L. Tennant, C., Rosen, A., and Tribe, K. (2002) ‘Deinstitutionalisation for long-term mental illness: a 6 year evaluation’, Australian and New Zealand Journal of Psychiatry, Vol. 36, 60-66. Hodder et al. (1998) “Down and Out in Sydney, Prevalence of mental disorders, disability and health service use among the homeless people in Inner Sydney”, Sydney City Mission. Holland, T. and Jacobson, J. (Co-chairpersons), Mental Health Special Interest Research Group (2001) ‘Mental health and intellectual disabilities: Addressing the mental health needs of people with intellectual disabilities’, International Association for the Scientific Study of Intellectual Disabilities. House of Representatives Standing Committee on Community Affairs (1995) ‘Inquiry into Aspects of Youth Homelessness’, A. Morris (Chair), Canberra. Human Rights and Equal Opportunity Commission (1989) ‘Our Homeless Children’, Report of the National Inquiry into Homeless Children by the
98 Human Rights and Equal Opportunity Commission (Burdekin, Chair), AGPS, Canberra. Human Rights and Equal Opportunity Commission (1993) ‘Human Rights and Mental Illness’, Report of the National Inquiry into the Human Rights of People with Mental Illness. Vols 1 & 2, AGPS, Canberra. Human Rights and Equal Opportunity Commission (1995) ‘Human Rights and Mental Illness Victoria’, Report of the reconvened Inquiry into the Human Rights of People with Mental Illness (Victoria), AGPS, Canberra. International Journal of Psychosocial Rehabilitation website (2002) ‘Assessment and Treatment of patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse’. Treatment Improvement Series. www.psychosocial.com Jaggs, D. (1990) ‘Institutions for Children and Young People 1850-1980’ School of Community Services and Policy Studies, Phillip Institute of Technology, Melbourne. See also Jaggs, D. (1986) ‘Neglected and Criminal: Foundations of Child Welfare Legislation in Victoria’, Phillip Institute of Technology, Centre for Youth and Community Studies. Jesuit Social Services (2001) ‘Connexions’ Victorian Public Health Awards for Excellence and Innovation, Melbourne. Keene, J. (2001) ‘Clients with Complex Needs. Interprofessional Practice’, Blackwell Science Ltd. UK. Keon-Cohen, B. (1992) ‘Can the Victorian Parliament abolish fundamental rights?’, Proceedings of Conference, Australian Institute of Criminology, October 1991, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 29-44. Keys Young Pty Ltd (1997) ‘Juvenile Justice services and transition arrangements’ a report to the National Youth Affairs Research Scheme, National Clearinghouse for Youth Studies, Tasmania. Kissane, K. (1990) ‘Are they mad or bad? Lawyers and psychiatrists differ on how to protect society from violent psychopaths’, Time Australia, Vol 5, No. 5, 42-43. Klin, A, and Volkmar, F. (2000) ‘Treatment and Intervention Guidelines for Individuals with Asperger Syndrome’, Asperger Syndrome, Klin, Volkmar, and Sparrow (Eds.) The Guildford Press, NY, London. Klin, A., Volkmar, F., Sparrow, S. Cicchetti, D., and Rourke, B. (1995) ‘Validity and Neuropsychological Characterisation of Asperger Syndrome: Convergence with Nonverbal Learning Disabilities Syndrome’, Journal of Child Psychology and Psychiatry, Vol. 36, No. 7, 1127-1140. Lamb E. H. (ed.) (1984) ‘The Homeless Mentally Ill’, APAP, Washington 1984. Lamb, H.R., and Bachrach, L.L. (2001) ‘Some perspectives on Deinstitutionalisation’, Psychiatric Services, Vol. 52, No. 8, 1039-1045. Lapidos, J. (1992) ‘Response to Inquiry into Mental Disturbance and Community Safety’, submission by the Prison Reform Group, in Second
99 Report upon the Inquiry into Mental Disturbance and Community Safety, Social development Committee, 221-224. Lightfoot, J. (1998) ‘Striking the balance – Abolition of the Victorian Governor’s Pleasure System’, Psychiatry, Psychology and Law, Vol. 5, No 2, Nov 1998, 265-269. Lindsay, F., and McDermott, F. (2000) ‘Dual Diagnosis or MISUD (Mental Illness Substance Use Disorder) A review of recent literature’, Psychiatric Disability Services, Victoria. Appended to Fox, A. (2000). Linehan, M. (1993) Cognitive-Behavioural Treatment of Borderline Personality Disorder, The Guilford Press, NY. Lucas, W. (1992) ‘A comment on the Community Protection (Violent Offenders) Bill’, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 5-11. Mc Donald P. (1993) ‘Confronting the Chaos’, A Report of the SANS Project, The Salvation Army, Victoria. Mc Donald, P. (2000) ‘Through the Wall. An address to practitioners at a forum on the Working Together Strategy’, Children Australia, Vol. 25, No. 1, 27-32. McDermott, F., and Pyett, P. (1993) ‘Not Welcome Anywhere: people who have both a serious psychiatric disorder and problematic drug or alcohol use’, Vols 1 & 2, Psychiatric Disability Services of Victoria (VICSERV). Mead, G. (1991) ‘Sentencing – the problem of balancing freedom and incarceration for persisting offenders and a discussion Victoria’s Garry David legislation’, Paper presented to CLE Seminar, Law Society of South Australia. Merkel, R. (1991) ‘Submission to the Social Development Committee: Community Protection (Violent Offenders) Bill’, Victorian Council for Civil Liberties, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 319-329. Mesobov, G. (1992) Treatment Issues with High Functioning Adolescents and Adults with Autism’, in Schopler and Mesibov (Eds.), High-Functioning Individuals with Autism, Plenum Press, NY, 143-155. Minkoff, K. (1989) ‘An integrated treatment model for dual diagnosis of psychosis and addiction’, Hospital and Community Psychiatry, Vol. 40, No. 10, 1031-1036. Minkoff, K. (2001) ‘Developing Standards of Care for Individuals with Co- occurring Psychiatric and Substance Use Disorders’, Psychiatric Services, Vol. 52, No. 5, 597-599. Minkoff, K. and Rossi, A. (1998) ‘Co-occurring Psychiatric and Substance Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies and Training Curricula’, Report of The Centre for Mental Health Services Managed Care Initiative. Monahan J, Steadman, H.J., Applebaum P.S., Robbins P.C., Mulvey E.P., Silver E., Roth, L.H., Grisso, T. “Developing a clinically useful actuarial tool for
100 assessing violence risk”, British Journal of Psychiatry, 2000; 176: 312-319. See also Policy Research Associates Website, http://www.prainc.com Morton, J. and Buckingham, B. (1994) ‘Service options for Clients with Severe or Borderline Personality Disorders’, A report prepared for Psychiatric Services Division, Victorian Government Mental Health Services. Morton, J., Clark, R., and Pead, J. (1999) ‘When Care is not Enough, a review of intensive therapeutic residential service options for young people in out-of-home care who manifest severe emotional and behavioural disturbance, and have suffered serious abuse or neglect in early childhood’, Report to Victorian Department of Human Services, Melbourne. Mullen, P. (2001) ‘Mental Health and Criminal Justice’, A review of the relationship between mental disorders and offending behaviours, and on the management of mentally abnormal offenders in the health and criminal justice services’, Prepared for the Criminology Research Council, August 2001. Mullen, P. Briggs, S., Dalton, T., and Burt, M. (2000c) ‘Forensic Mental health Services in Australia’, International Journal of Law and Psychiatry, Vol. 23, No 5-6, 433-452. Mullen, P., Burgess, P. (2000b) ‘Community care and schizophrenia’, Authors reply, The Lancet, Vol. 355, May 20, 1827-1828. Mullen, P., Burgess, P., Wallace, C., Palmer, S., and Ruschena, D. (2000a) ‘Community care and criminal offending in schizophrenia’, The Lancet, Vol. 355, Feb 19, 614-617. Murray, D. (1998) ‘Ready to make the necessary Connections’, Parity, Vol. 11, No 8. National Health and Medical Research Council (1992) ‘Breaking Out: Challenges in Adolescent Mental Health in Australia’ Kosky R., Eshkevari, H., Kneebone, G. (Eds.), AGPS, Canberra. Norden, P. (1992) ‘Brosnan Centre Response to the draft proposals for a Community (Violent Offenders) Bill’, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 255-261 North Western Health (1997) ‘Waratah Area Homeless Outreach Psychiatric Service (WAHOPS): Program Description’. Inner West Area Mental Health Service. NSW Health Department (2000) ‘The Management of People with a co- existing mental health and substance use disorder’, Discussion paper, Dual Diagnosis project, NSW. NSW Law Reform Commission (1996) ‘People with an Intellectual Disability and the Criminal Justice System’, Report No. 80, Sydney. Office of the Public Advocate (2002) ‘Challenges in Community Living’, http://www.publicadvocat Ogloff, J., Roesch, R. and Eaves, D. (2000) ‘International Perspectives on Forensic Mental Health Systems’, International Journal of Law and Psychiatry, Vol. 23, No. 5-6.
101 Olivieri, R. (2000) ‘Towards effective intersectoral action; understanding how to collaborate to achieve better outcomes for people with high and complex needs’, Homelessness in the 21st Century: working together for change. South Australian Department of Human Services, Adelaide, 92-98. Oregon Department of Human Services (2000) Report of the Statewide Taskforce on Dual Diagnosis, D. Walker (Chair). Osher F.C., Kofoed, L.L. (1989) ‘Treatment of patients with psychiatric and psychoactive substance abuse disorder’. Hospital and Community Psychiatry, Vol. 40, 1025-1030. Owen, L., Lunken, T., Davis, C., Cooper, B., Frederico, M., and Keting, T. (2000) ‘Pathways to Interdependence and Independence: The Leaving Care Initiative’, A study and good practice development project prepared for Child Protection and Juvenile Justice, Department of Human Services, Victoria, Department of Social Work and Social Policy La Trobe University, Bundoora, Victoria. Ozanne, E., Bigby, C., Forbes, S., Glenne, C., Gordon, M. and Fyffe, C. (1999) ‘Reframing Opportunities for people with an Intellectual Disability’, School of Social Work, University of Melbourne, pp 63-97. Perry, B. (1997) ‘Memories of Fear. How the Brain Stores and Retrieves Physiologic States, Feelings, Behaviours and Thoughts from Traumatic Events’, in J Goodwin and R Attias (Eds.) Images of the Body in Trauma, Basic Books. Rayner, M. and Cockram, J. (1996) ‘The response of the law to intellectual disability in Western Australia 1829-1993’, in Under Blue Skies: the social construction of intellectual disability in Western Australia, 137-165. Reynolds, A. and Inglis, S. (2001) ‘Effective programme linkages: an examination of current knowledge with a particular emphasis on people with mental illness, positioning paper’, Australian Housing and Urban Research Institute, Victoria. Ridgely, S., Lambert, D., Goodman, A., Chichester, C. and Ralph, R. (1998) ‘Interagency Collaboration in Services for People with Co-Occurring Mental Illness and Substance Use Disorder’, Psychiatric Services, Vol. 49, No. 2, 236-238. Sciacca, K. (1991) ‘An Integrated Treatment Approach for Severely Ill Individuals with Substance Disorders’, in New Directions For Mental Health Services, Jossey-Bass (sourced from www.psychosocial.com/dualdx/). Shepherd, G. (1996) ‘A Redirection in partnership; government and non government services working together’, National Conference on Homelessness, Council to Homeless Persons, Melbourne. Simpson, A., Brinde, P., Laidlaw, T., Fairley, N. and Malcolm, F. (1999) ‘The National Study of Psychiatric Morbidity in New Zealand Prisons’, A Report to New Zealand Government Department of Corrections. Smith, G. (1980) ‘Social Need: Policy, Practice and Research’, Routledge Kegan & Paul, London.
102 Social Equity Consulting Group (2000), ‘DisAbility Services’ Criminal Justice Program Strengthening Service Provision’, A report prepared by Bunting et al. in association with Dr Meredith Martin for the Victorian Department of Human Services, Melbourne. Spectrum (2001a) ‘Complex Clients’ Department of Human Services, Melbourne. Spectrum (2001b) Report to Complex Clients Working Group, April 27th 2001, unpublished. Substance Abuse and Mental Health Services Administration and National Association of State Alcohol and Drug Abuse Directors (1998) ‘Release Report on Preliminary Information on Services to Individuals with Co-existing Substance Abuse and Mental Health Disorders’, July 17, 1998, sourced from www.psychosocial.com/dualdx/ Success Works (2001) ‘Evaluation of the High Risk Service Quality Improvement Initiative’, Report for Victorian Department of Human Services, Melbourne, March 2001. Tait, S. (2001) ‘Disability Law Reform’. Paper delivered at the Guardianship and Administration National Conference, Melbourne, 19th October, 2001. Teesson, M., Gallagher, J., & Ozols, S. (1998) ‘The Gemini Project: An Evaluation of a Treatment Program for Persons with Serious Mental Illness and Substance Misuse’, NDARC Technical Report No. 53. Thomson Goodall Associates (1999) ‘Model of Intensive Support for people who are homeless, and have a range of complex support needs’, The Salvation Army Crossroads Network, Melbourne. Thomson, D. (1990) ‘Civil liberties aspects of preventive detention of dangerous persons, focusing on the case of Garry Webb’. Paper presented to the Rationalist Society of Australia 54th Conference, Warburton, Victoria. Tonge, B. (1996) Autism: time for a national approach to early assessment and management’, Editorial, MJA, Vol. 165, 244-245. Tonge, B., Brereton, A., Gray, K. and Einfeld, S. (1999) ‘Behavioural and emotional disturbance in high-functioning autism and Asperger syndrome’, Autism, Vol. 3, No. 2, 117-130. Toomey, B, First, R., Rife, J. and Belcher, J. (1989) ‘Evaluating community care for homeless mentally ill people’, Social Work Research & Abstracts, December 1989, Vol. 25, No. 4, 21-26. UK Government British Home Office and Department of Health (1999) ‘Managing Dangerous People with severe personality disorder, proposals for policy development’, Department of Health, London. UK Government British Home Office and Department of Health, United Kingdom (2000a), ‘Reforming the Mental Health Act, Part II High Risk Patients’, London. UK Government British Home Office, HM Prison Service, and Department of Health (2000b) ‘Managing dangerous people with severe personality disorder’, London.
103 USA National Association of State Mental health Program Directors and National Association of State Alcohol and Drug Abuse Directors (1998) ‘National Dialogue on Co-occuring Mental Health and Substance Abuse Disorders’, Washington, DC, sourced from www.dualdiagnosis.org/library/ USA National Association of State Mental health Program Directors and National Association of State Alcohol and Drug Abuse Directors (1999) ‘Financing and Marketing the New Conceptual Framework for Co-occurring Mental Health and Substance Abuse Disorders A Blueprint for Systems Change’, Final report of the Joint Task Force, June 1999. Victorian Dual Disability Service (2001) ‘development of a statewide Mental health Service for adults with intellectual disability and mental illness’, paper for THEMS Conference. see www.vdds.org.au/ Victorian Government (2001) ‘Report of the Review Panel Appointed to Consider the Operation of the Disability Services Statewide Forensic Service’, (Justice Frank Vincent, Chair) September 2001. Victorian Government (2001) “Report of the Review Panel appointed to consider leave arrangements for patients at the Victorian Institute of Forensic Mental Health”, (Mr Vincent, Chair) May 2001. Victorian Government Attorney General’s Department (1992) ‘Draft proposals for a Community Protection (Violent Offenders) Bill, in Social Development Committee (1992) ‘Inquiry into Mental Disturbance and Community Safety, Second Report, incorporating a range of views on the Draft Community Protection (Violent Offenders) Bill’, April, pp 337-351. Victorian Government Department of Human Services (1996) Interim Protocol between the Office of Correctional Services Commissioner, Department of Justice and Disability Services Division. Victorian Government Department of Human Services (1997a) ‘Secure Welfare Services Review’, Melbourne. Victorian Government Department of Human Services (1997b) ‘Disability Homeless Outreach and referral Service’ (DHORS). Victorian Government Department of Human Services (1997c) ‘Victoria’s Alcohol and Drug Treatment Services. The Framework for Service Delivery’, Aged, Community and Mental Health Division. Victorian Government Department of Human Services (1998a) ‘The Framework for Service Delivery, Better Outcomes Through Area Mental Health Services’, July 1998, p 2. Victorian Government Department of Human Services (1998b) ‘Victoria’s Mental Health Services’, Melbourne. Victorian Government Department of Human Services (1999a) ‘Managing Clients Initiative. Multi-service Clients Project’, Community Care Division. Victorian Government Department of Human Services (1999b) ‘The Working Together Strategy. A Quality Improvement Initiative involving Mental Health, Protection and Care, Drug Treatment Services and Juvenile Justice’, February, 1999.
104 Victorian Government Department of Human Services (1999c) ‘Managing Clients Initiative Client Volumes Project report, July 1999. Victorian Government Department of Human Services (2000a) ‘Supporting the needs of individuals with high complex behaviours: a definition and service framework’, Introductory Paper prepared by High Complex Needs Project, Policy and Program Development Section, DisAbility Services, Melbourne. Victorian Government Department of Human Services (2000b) ‘Supporting the needs of Individuals with High Complex Behaviours’, DisAbility Services Division, July 2000. Victorian Government Department of Human Services (2000c) “Defining Statewide & Specialist Services”. The Department of Human Services Response and Report of the Review of Statewide & Specialist Mental Health Services. Victorian Government Department of Human Services (2000d) ‘The Working Together Strategy, Program Description Paper’, Melbourne. Victorian Government Department of Human Services (2001a) ‘Statewide Forensic Services, Policy and Guidelines’, Melbourne. Victorian Government Department of Human Services (2001b) Complex clients. Survey undertaken by DisAbility Services. Victorian Government Department of Human Services (2001c) ‘Complex Clients Regional Overview’, Unpublished, DisAbility Services, Melbourne. Victorian Government Department of Human Services (2001d) ‘Draft State Disability Plan’, Melbourne. See [http://hnb.dhs.vic.gov.au/ds/disabilitysite.nsf/pages/plan?Open] Victorian Government Department of Human Services (2002a) Complex Clients Project, Project Brief, Operations Division. Victorian Government Department of Human Services (2002b) ‘Victorian Homelessness Strategy: Action Plan and Strategic Framework: Directions for Change’, Community Building Division. Victorian Government Ministerial Advisory Committee (2001) ‘Building Solutions for Individuals and families who experience homelessness - Working Report of the Victorian Homelessness Strategy’, Department of Human Services, Melbourne. Victorian Government Social Development Committee (1991) ‘Inquiry into Mental Disturbance and Community Safety, First Report: Young People at Risk’, June. Victorian Government Social Development Committee (1992a) ‘Inquiry into Mental Disturbance and Community Safety, Third Report. Response to the Draft Community Protection (Violent Offenders) Bill’, April. Victorian Government Social Development Committee (1992b) ‘Inquiry into Mental Disturbance and Community Safety, Fourth and Final Report’. August. Victorian Government Suicide Prevention Task Force (1997) ‘Suicide Prevention’ Task Force Report, June.
105 Vincent, F. (2001) ‘Report of the Review Panel Appointed to Consider the Operation of the Disability Services Statewide Forensic Service’, Justice Frank Vincent (Chair), September 2001. Wallace, C., Mullen, P., Burgess, P., Palmer, S., Ruschena, D., Browne, C. (1998) ‘Serious criminal offending and mental disorder’, British Journal of Psychiatry, 172, 477-484. Weir, W. (1997) ‘Housing and Supported Accommodation Strategies for people seriously affected by mental illness’, Report to Centre for Mental Health, NSW Health Department. Western Australian Department of Human Services (2002) ‘Strategic Plan for Mental health Services in the South West Corridor’, Perth Williams C. (1992) Coping with the highly dangerous: issues of principle raised by preventive detention’, in Second Report upon the Inquiry into Mental Disturbance and Community Safety, Social Development Committee, 71-88. Williams, C. (1990) ‘Psychopathy, mental illness and preventive detention: issues arising from the David case’, Monash University Law Review, Vol 16, No 2, 161-183. Wilson, B. (1999) ‘Shifts in Mental health policy’, Health Policy in the Market State, Hancock, l. (Ed.), Allen & Unwin. Wood, D. (1990) ‘A one-man dangerous offenders statute: the Community Protection Act 1990’, Melbourne University Law Review, Vol. 17, No. 3, 497-505. Yeatman, A. (1996) ‘Getting Real’, The final report of the review of the Commonwealth/State Disability Agreement, AGPS. Young, Y., Sigafoos, J. Suttie, J., Ashman, A. and Grevell, P. (1998) ‘Deinstitutionalisation of persons with intellectual disabilities: A review of Australian studies’, Journal of Intellectual & Developmental Disability, Vol. 23, No. 2, 155-170. Zalewski, R. (2001) ‘Preventive detention: justified or justice denied?’, Law Institute Journal, Vol 66, No 11, 1008-1011. Zufferey, C. (2002) ‘Towards ‘client centred’ Service Provision for Homeless People with High and Complex need’, Parity, Vol 15, No 5.
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