Reflective practice and personal development

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CROSSING THE LINE

The impact of poor living conditions and hygiene continued to be seen in the endemicity of hepatitis B (HBV) in rural and remote communities, although, as noted earlier, HBV was on the decline in urban settings. As many as 73% of Aborigines in some remote locations in the Northern Territory have shown evidence of exposure to hepatitis. In the later 1980s, the HBV carrier rate in non-indigenous Territorians was less than 0.1-1%, a rate similar to that found in the rest of non-indigenous Australia (CDHHS, 2004). The relative contribution of sexual and needle-sharing transmission to spread of HBV among indigenes is unknown, but the potential is significant, given the very high HBV carrier rates in some communities. Most infection appears to take place perinatally, through transmission from mother to child, or early in life through ?horizontal' transmission; overcrowding directly assists horizontal spread. The commonwealth provided, free from the beginning of 1987, universal vaccination for Aboriginal neonates (Gale, 2007).

Alcohol abuse is a major cause of premature mortality and excess morbidity. While a considerable percentage of Aboriginal people do not drink alcohol -- an estimated 10 to 35% of males abstain, and of females 39 to 80% -- a larger proportion of drinkers consume excessive quantities. Binge' drinking is more frequently practiced than in the general community. As a direct cause of mortality, alcohol abuse is responsible for about 10% of deaths in Aboriginal communities (Roe, 1976). It contributes to violence, accidents, child neglect, violent crime and imprisonment. Alcohol was seen as significantly associated with deaths in police custody by the Royal Commission into Aboriginal Deaths in Custody in the early 1990s (Sax, 1984).

Easy availability of alcohol in rural and remote communities contributes to abuse. For some time Aboriginal communities have pursued various types of self-help. Com- munity interventions have included night patrols, dry (alcohol-free) areas, substance abuse programs, sobering-up shelters, drying-out ?farms' and organized efforts to contain growth of licensed outlets A great many communities endure social, economic and environmental deprivation, with low levels of education and income, poor community infra- structure, discrimination and high levels of unemployment, imprisonment and inadequate housing. This deprivation is the ultimate cause of the health inequality (Smith, 2006). By the late 1980s, the vast majority of Aborigines aged fifteen to twenty-four years had some schooling. Even in the Northern Territory more than 93% received some. But they quit school at an earlier age and were less likely to receive postsecondary education than other Australians.

The royal commissioner on Aboriginal deaths in custody said in his 1991 report that education systems failed to provide equitable participation. The National Review of Education for Aboriginal and Torres Strait Islanders pointed out in 2004 that the education offered had to be regarded as appropriate by Aborigines themselves. However, high unemployment rates commonly result from lack not of skills but of job opportunities. The average Aboriginal unemployment rate throughout the country is three times the rate of non-Aborigines. The occupation distribution is greatly different, with Aborigines overrepresented in unskilled and semiskilled occupations. A much larger proportion derives income from social security benefits than do non-Aborigines (CDHHS, 2004).

There is a wide range of socioeconomic status, from a few living in comparative affluence to the great majority in poverty, with the highest incomes in cities like Canberra, Melbourne and Hobart, and the poorest in rural and remote locations that have been seriously affected by rural economic recession. Where 70% of Australians are home owners, about 26% of Aborigines are in this category. Indeed, housing inadequacy is a major social and health problem. In the early 1990s, a national survey found that while Aboriginal families accounted for 1.4% of total families, they represented 22% of families designated homeless and 38% of families occupying improvised housing (tents, caravans, boats or sheds). Overcrowding was four times the level of overcrowding in the non-Aboriginal population. Inadequate housing was worst in rural and remote locations. In the Northern Territory, 29% of families were homeless, with another 22% living in overcrowded conditions. Another indicator of inadequate housing is the degree of availability of ?health hardware? To enable healthy living-water supply, waste disposal systems, washing facilities and toilets (CDHHS, 2004).

A 2008 environmental health review of the Anangu Pitjantjatjara Lands in remote South Australia found that 50% of the people were not housed; 55% of hot water and 40% of cold water outlets were not working, and 57% of waste-water systems did not function. In yard areas, which were living space for many, 25% of taps did not work. Over- crowding was common. Individuals per house averaged 8.3. A 2002 national survey of infrastructure in rural and remote communities revealed that 34% lacked adequate water supplies. Better health can follow from better housing only if infrastructure is appropriately designed and reliably main- trained (Gale, 2007).

Critical Reflection: Mental Health Services in Their Social Context

The discussion above has mainly focused on the relationship between society and forms of knowledge about mental health. Societal influences are also relevant when we come to understand the provision of mental health services. The notion of 'mental health services' is actually quite recent. Up until the first part of the twentieth century there were only hospitals, clinics, and asylums. The notion of 'services' has re- placed these individual descriptions of facilities in the last 50 years.

During the nineteenth century in Western Europe and North America most countries developed centrally regulated asylum systems. The emergence of large asylums in most localities was associated with the need to control nonproductive deviance in increasingly urbanized and complex capitalist societies. In other words, economic life was disrupted or impaired by madness ('lunatics' or 'dements') and by those with learning difficulties ('aments'). Both of these groups were 'warehoused' in asylums to remove their negative impact on socioeconomic order and efficiency just as orphans, the physically sick, and the elderly were placed in poorhouses. Professionals at that time took little or no interest in sane people who were frightened or sad (the neuroses). This changed after the First World War, when the 'shell shock' problem altered the focus of professional interest. Warfare ensured that stress induced problems, later to be called 'battle neurosis' or 'posttraumatic stress disorder,' recurringly shifted professional attention away from madness and toward neurosis during the twentieth century. This also expanded the range of interventions offered or preferred by professionals to include talking treatments. As a result, psychiatric treatment became more eclectic, although it remained dominated by biomedical interventions. During periods of peacetime, the focus on madness returned, along with biological treatments in institutional settings (Smith, 2006).

After the Second World War, the old asylum system came into crisis for a number of reasons:

1. The expanded remit of psychiatry and its associated professions, to including talking treatments with neurotic patients in community settings, in- creased expectations that mental health services should shift away from biomedical treatments inside institutions (Roe, 1976).

2. In the wake of the widespread cultural shock of the Nazi concentration camps, Western liberal democracies witnessed a popular disquiet about segregation. Also, lessons about the disabling impact of institutionalization ('institutional neurosis') were drawn from observations in the camps of ritualized, rigid, and stereotyped behavior of their inmates (Smith, 2006).

3. Large institutions were expensive and placed a large fiscal burden upon government budgets. Deinstitutionization offered itself as a cost-cutting exercise.

4. Doubts about institutional life were reinforced by research on its negative impact from social psychiatry, sociology, and from dissent within clinical psychiatry ('antipsychiatry').