1. ‘A patient not detained is a patient not treated’. Is this public mental health in Australia? Maree Livermore, Academic Unit of Psychological Medicine, ANU Medical School. The impact of coercive mental health law on access to mental health services in Australia.

2. Access is still inadequate… 500,000 presentations annually – > 2/3 turned away with little or no treatment (Crosbie, 2010) Not serviced: prevention early intervention community-based sub-acute support (housing, employment) services for young people, older people, families… coordination role

3. MH Law and access Focus on low-prevalence, high- seriousness conditions (in services and the law). MH law does not address access (Petrila 1992) Right to health? CRPD How can MH law ‘leverage access’? (Carney, 2009 McSherry 2008)

4. The provenance of mental health law (NSW) 1843 Lunacy Act – dangerous ‘lunatics’ and ‘idiots’ 1878 Process provisions 1958 Medical paternalism ‘mentally ill person’ 1970-early 80s Civil liberties. To date: Human rights

5. Mental Health (Treatment and Care) Act 1994 (ACT) Part 2 Objectives Part 4 Mental health orders Part 5A Interstate application of mental health laws Part 6 Rights Part 7 ECT and psychiatric surgery Part 8 Referrals under Crimes Act and C&YP Act Part 9 Procedural matters—ACAT Part 10 Chief psychiatrist and mental health officers Part 10A Care coordinator Part 11 Official visitors Part 12 Private psychiatric institutions Part 13 Miscellaneous

6. Current social, political and economic context Scarce resources, high demand Federalism Traditional ‘almshouse’ role of hospitals departing… Social control to an access model (Lincoln, 2007)

7. Reforming the law to facilitate access Involuntary treatment criteria and Tribunal process. (Szmukler, Carney McSherry) Even more fundamentally: Does our current model of mental health law, by its emphasis on coercive treatment and the processes it generates inhibit effective access to mental health services?

8. Effect of coercive mh law on people with mental illness What is the effect on help-seeking behaviour? (e.g. Swartz, 2003) How does mental health law affect stigma?

9. Influence of coercive mh law on clinicians… How does mh law influence treatment pathways? - ‘making a case’: Lincoln (2007) Is mh law engaged for the management of scarce resources? ( Engelman, 2007; Lorant et al, 2007)

10. Coercive MH Law and government policy - Differences in applicable law? - In availability of voluntary services? ( Lorant et al 2007 ) Do jurisdictions with higher use of legal coercion have lower voluntary service availability? If yes, are these differences supported by epidemiological data? If no – the law may be a barrier to treatment… Wildly differentiated rates of involuntary treatment between Australian juris. ( National Resid. Mental Health Care Database AIHW, 2007 )

11. Implications for reform (1) Reduction in the role of risk in measurement of clinical need and legal criteria. Service planning and funding by Commonwealth. Provisions ensuring involuntary measures truly ‘last resort’.

12. Implications (2) – redress the balance Legislation to provide for: treatment pathways; assessment, individual care plans and service coordination; opt in/opt out, reciprocal rights and responsibilities. Specific provisions – younger and older people. Assertive outreach

13. mliv@livermore.com.au