About alternativesThe alternatives component of the 4As Framework recognises the need for an expanded range of treatment and community support options for people who have experienced mental illness. Mental health care must go beyond the traditional medical model to acknowledge the holistic nature of mental health, which is made up of social, emotional, physical and spiritual wellbeing.
A useful understanding is derived from Maslow's Hierarchy of Needs, which are illustrated in figure 3. This hierarchy maintains that there are common human needs and that these must be satisfied in a particular order: only when the lower order needs of physical and emotional wellbeing are met can energy be devoted to higher order needs. Furthermore, total wellbeing encompasses meeting all the hierarchy of needs.
A holistic approach is required to address the entire hierarchy of needs, which translate into the risk and protective factors for mental health shown earlier in Risk and protective factors for mental health. This means provision of a broad-based service response across both the health and human services systems, and this has started to occur in many communities. For example:
- the role of primary care, including general practice, is now an integral part of the mental health care system;
- peer support is increasingly recognised for its vital role;
- housing, employment, and other forms of psychiatric disability and community support are now identified as essential needs; and
- the services provided by allied health professionals are being acknowledged, expanding therapeutic options to include cognitive and behavioural therapies, family therapies, relaxation and meditation, and counselling.
The major barriers to providing alternatives relate to planning, funding and communication challenges across services and sectors. To overcome these, collaborative partnerships must be formed, where the input of all service providers is recognised and respected. Shared understanding and common goals that prioritise the wellness needs of the consumer can eliminate the barriers to providing holistic continuing care.
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Diversity is something that is celebrated in Australia and this spirit needs to be reflected in our service alternatives for people who have experienced mental illness, not only by providing alternative services that meet unique needs, but also by ensuring that all service providers are responsive to the diverse range of needs of their consumers. Alternatives must be available to address all the risk and protective factors for mental health, recognising that these vary with age, cultural background, location and personal circumstances.
Rural and remote communities can be particularly disadvantaged when it comes to the availability of alternatives, as often even the most basic mental health services are limited. The service providers in many communities overcome these barriers by being more flexible and collaborative, and working in non-traditional and innovative ways, particularly through the use of new technologies and flexible service arrangements.
Children and adolescents are at a life-stage that is fundamentally different to that of adults. Important alternatives for young people include family-based therapies and options to enable continued education. Young people also have unique needs around the development of independence and autonomy (which can include risk-taking behaviours), sexual identity, and vocational goals.
At the other end of the lifespan, older adults also have specific needs. Some older adults have experienced a lifetime of mental illness with repeated hospitalisations and are at high-risk in the community. Physical illness and disability increasingly become risk factors with age, along with bereavement and social isolation.
For many Aboriginal and Torres Strait Islander peoples, the risk factors for mental health are heightened, and include cultural stress, grief, trauma and historical trauma. As a consequence, they are at increased risk of socio-economic disadvantage, selfharm, suicide, incarceration and violence, which become additional risk factors. Alternatives need to prioritise the development of community resources that sustain wellbeing for the individual and their whole community.
Furthermore, some common Western service alternatives are inappropriate for Aboriginal and Torres Strait Islander peoples. For example, hospitalisation is a traumatic event that causes the added stress of being removed from community and traditional ways of life for people who live in remote communities and more traditional lifestyles. More culturally appropriate alternatives are needed, including more Aboriginal health and mental health workers, traditional healers, narrative-based therapies and culturally appropriate adaptations of cognitive-behavioural therapies.
People from culturally and linguistically diverse backgrounds also have unique risk and protective factors for mental health, and these need to be addressed through culturally appropriate treatment and support alternatives. In particular, refugees and victims of torture and trauma have additional risk factors that must be addressed. Risk and protective factors vary across communities, and each community needs to develop the capacity to identify and respond to their unique circumstances. However, all services need to be culturally safe and aware and understand the importance of cultural competence, as well as culturally-specific alternatives being available when this is essential to the wellbeing of a particular population group.
Figure 3. Representation of Maslow's hierarchy of needs9
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Text version of figure 3Maslow's hierarchy of needs is presented as a triangle. Starting at the top of the triangle and moving down, the needs are:
- self-actualisation - personal growth and fulfillment
- belongingness - family, relationships, connectedness
- esteem needs - achievement, status, responsibility, reputation
- safety needs - protection, security, limits, stability
- biological and physical needs - air, water, food, shelter, warmth, sleep, sex.
OutcomesTo implement the Alternatives component of the 4As Framework, the following outcomes need to be achieved:
- Service alternatives are available to meet all the needs of people who have experienced mental illness, and their families and carers. This means that service alternatives are provided that are:
- holistic, acknowledging the whole person and all their physical, social, emotional and spiritual needs;
- address all the risk and protective factors for mental health;
- appropriate to the age and life-stage of the person who has experienced mental illness;
- culturally safe and appropriate; and
- able to overcome barriers of distance.