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 environmental, financial, functional, mental, occupational, physical, recreational, sexual, spiritual and
social aspects of who we are. The range of disciplines or fields of health includes:
• ambulance officers and paramedics
• counsellors
• dietitians and nutritionists
• Indigenous health workers
• medical practitioners
• midwives
• nurses, including enrolled and registered nurses, and nurse practitioners
• occupational therapists
• pastoral workers and chaplains
• pharmacists
• physiotherapists
• psychologists
• social workers.
Each of these disciplines has an important role to play in the delivery of health care.
For example, paramedics are frontline health professionals who provide emergency or life‐saving
health care, and other unscheduled care, out‐of‐hospital and in the community. This includes stabilising
a person’s health condition for or during transport to hospital. Paramedics often work with ambulance
officers and specialise in medical emergencies and the management of high acuity patients.
Another important group of health professionals is social workers, who are committed to pursuing
social justice, enhancing quality of life and developing the full potential of individuals, groups and com-
munities. In view of the importance of the social determinants of health in influencing the health out-
comes of people and communities, the role of social workers in the multidisciplinary team is essential.
Occupational therapists support the person to attend to their own everyday needs and preferences
(often referred to as ‘functional needs and preferences’) as well as participate in meaningful activities.
Enabling people to be independent and self‐sufficient is integral to supporting good health in our society.
Occupational therapists also work with families, groups and communities, and are becoming increas-
ingly involved in addressing the effects of social, political and environmental factors that contribute
to the exclusion of people from employment. This is in addition to facilitating the personal, social and
recreational activities in which a person would like to become involved.
Other health professionals include counsellors, dietitians or nutritionists, Indigenous health workers,
pastoral workers and chaplains, pharmacists and physiotherapists. Each of these health professionals
play a significant role in delivering health care to people with mental health issues. The roles of these
health professionals will vary according to the scope of practice of each profession, and can range from
crisis or emergency care, to brief consultation or ongoing support. Whatever their scope of practice,
all health professionals will require some understanding of what is required to help the person who is
affected by symptoms of mental illness.
In the field of mental health, there are a number of health professionals with quite specific roles, and
this can sometimes be confusing. For example, many people are uncertain about the difference between
a psychiatrist and psychologist. A psychiatrist is a medical practitioner who has undertaken additional
study and acquired a very high level of expertise in the diagnosis and treatment of mental illness.
A particular focus of the care and treatment provided by a psychiatrist — like all medical practitioners
— is the physical or biological aspects of a person’s illness. A psychiatrist can prescribe medications and
admit a person to a hospital. Some psychiatrists have also been trained to provide psychotherapy or other
forms of psychological therapy.
In contrast, psychologists and clinical psychologists have been trained to provide psychological inter-
ventions or therapies for people. The focus of psychologists and clinical psychologists is the cognitive
and behavioural aspects of a person. While both the psychologist and clinical psychologist can pro-
vide therapy, the clinical psychologist holds a master’s degree in clinical psychology, which means that

CHAPTER 1 Mental health care in Australia 3

8
they can provide interventions that are more complex than psychologists. Neither the psychologist nor
clinical psychologist, however, can prescribe medication or admit a person to a hospital.
The most common health professional in the field of mental health is the nurse. Some people are
confused by the different types or levels of nursing and para‐nursing roles, which include assistants
in nursing, enrolled nurses, registered nurses and nurse practitioners. Each of these categories has a
different educational requirement and scope of practice. Nurses who work in the field of mental health
are sometimes called psychiatric nurses, but ‘mental health nurse’ is the preferred terminology. This
is because ‘psychiatric’ has biomedical connotations and a nurse’s scope of practice is far wider than
biomedicine alone. Generally, nurses provide care to people, around the clock, to help address the many
different needs and preferences of the person. The approach of the nurse is defined by holism, encom-
passing all aspects of personhood, not just the physical needs.
The term ‘mental health nurse’ is often used to describe the nurse, enrolled or registered, who works
in a mental health‐related field. However, the Nurses and Midwifery Board of Australia (NMBA), the
regulatory authority for nurses and midwives that is part of the Australian Health Practitioner Regulation
Agency (AHPRA), has no special category for ‘mental health’ or ‘psychiatric’ nurse. The Australian
College of Mental Health Nurses — the national professional body for mental health nursing — admin-
isters a credential for registered nurses who hold a specialist postgraduate qualification and can demon-
strate substantial and current experience in the field of mental health, as well as ongoing professional
development. Credentialed mental health nurses are often leaders in public mental health services, as
well as the defence health and justice health systems; and can work as autonomous practitioners in the
primary health care context, providing care to people with complex symptoms of mental illness.
Just as important to the multidisciplinary team are the support workers, including peer workers, who
are employed by community managed organisations to provide counselling, social and recreational sup-
port, housing and accommodation support, assistance to obtain employment, and opportunities for edu-
cation. As explained later in this text, there are many different social determinants of mental health
and illness. Health professionals do not work in a vacuum. With one in five Australians experiencing
symptoms of mental illness at some stage in their lives, the delivery of high quality mental health and
support services has become an increasingly important focus for governments and communities alike.
There is a need, then, for health professionals, regardless of discipline or specialty, to develop a greater
understanding of mental health and illness, as well as the diverse members of the multidisciplinary team
who deliver services to people with mental illness, and thereby enable the best possible outcomes for
those in need.

Mental health and mental illness

The term ‘mental health’ has different meanings for different people in different contexts. In Australia,
the field of mental health describes an area of health care that focuses on the psychological, emotional
and behavioural wellbeing of the population. With the development and implementation of the National
Mental Health Strategy in the early 1990s, governments across Australia, at the national and state or
territory levels, joined together to define mental health as the capacity of individuals and groups to
interact with one another and their environment in ways that promote subjective wellbeing, optimal
development and use of mental abilities (cognitive, affective and relational); and to achieve individual
and collective goals consistent with justice (Australian Health Ministers 1991). This national definition
has remained unchanged over the years.
Mental ill‐health is most commonly referred to as mental illness or disorder in Australia. According
to the Australian government, a mental illness is a health problem that significantly affects how a person
feels, thinks, behaves and interacts with other people (Australian Government 2013). Mental illness
is diagnosed according to standardised criteria, such as that provided by the DSM‐5 or ICD‐11 (the
chapter that looks at assessment in the mental health context has futher information). One reason the
term ‘mental illness’ is so commonly used to describe a mental health problem is because the Australian
health system continues to be dominated by the biomedical approach to treatment and care.

4 Mental health care

9
 A mental health problem also interferes with how a person thinks, feels, and behaves, but to a lesser
extent than a mental illness (Australian Government 2014). Mental health problems are more common
and less severe than mental illnesses or disorders, and include the mental ill‐health that can be experi-
enced temporarily as a reaction to the stresses of life. A person with a mental health problem may
develop a more severe mental illness if they are not supported effectively (Australian Government 2014).

THE BIG PICTURE

The mental health of first responders

Many first responders (such as those who work
in ambulance and paramedicine services, fire
and rescue services, police forces and state
emergency services) are involved in or witness
traumatic events. Over time, this may affect
the mental health of the first responders. The
mental health issues experienced may include
depression, anxiety, post‐traumatic stress dis-
order, relationship difficulties, alcohol and/or
substance abuse, and suicidal thoughts.
Heads Up, or the Mentally Healthy Workplace
Alliance ([Link]), is sponsored by
a range of organisations, including the Australian
government and beyondblue, to support the
development of mentally healthy workplaces, across Australia. This includes helping managers to develop
an action plan aimed at creating a workplace that supports the mental health of employees. It also in-
volves helping employees to take responsibility for their own and their colleagues mental health, and
educating employees on how to have a conversation with colleagues who they may be worried about.
The Good Practice Framework for Mental Health and Wellbeing in First Responder Organisations has
been developed by Heads Up to enable first responder organisations to support the mental health and
wellbeing of their employees. All health professionals are encouraged to read this handbook and consider
how they can better help first responders to manage their levels of stress.
Another set of guidelines for first responders has been developed by the Black Dog Institute
([Link]), an Australian not‐for‐profit organisation, which has become a leader in
research related to the diagnosis, treatment and prevention of mood disorders such as depression and
bipolar disorder. The Black Dog Institute joined forces with a number of universities, as well as the Centre
for Posttraumatic Mental Health and St John of God Hospital, to develop Expert Guidelines in the Diag-
nosis and Treatment of Post‐Traumatic Stress Disorder in Emergency Service Workers. These guidelines
have been developed to improve the support given to emergency workers who report ongoing psycho-
logical consequences from exposure to trauma.
These guidelines provide good preliminary resources for health professionals who work with first re-
sponders. Health professionals are encouraged to familiarise themselves with the principles involved in
helping those who experience traumatic events in the course of their work.

Biomedical approaches to health care

The biomedical perspective evolved after the Age of Enlightenment, a period which began in the late
seventeenth century, ended in the late eighteenth century, and was characterised by the advancement of
scientific knowledge. The Age of Enlightenment saw the development of the ‘rational’ explanation of
health and illness. Supported by the theories of the French philosopher, René Descartes, the body was
viewed as a material object that could be understood only by scientific study and physical examination
(Berhouma 2013). In contrast, the mind was posited as part of a higher order, understood through intro-
spection. As such, the body and mind were separated into two distinct entities, with illness considered as
either somatic (physical) or psychic (mental) (Hamilton & Hamilton 2015). This philosophy paved the

CHAPTER 1 Mental health care in Australia 5

10
way for the development of an area of science now known as biomedicine, which focuses on the somatic
or physical aspects of illness (Colborne & MacKinnon 2003).
Today, the biomedical approach to the treatment of illness is viewed by many as a paternalistic or
vertical approach to health care. It involves ‘expert’ health professionals assessing the symptoms of a
person, making a diagnosis and devising treatment based on their scientific knowledge of the disease
process. In turn, the unwell person follows the directions provided by the expert health professional to
achieve a reduction in the severity of their symptoms (Deacon 2013). The biomedical approach focuses
on cause (disease or condition), effect (illness or deficiency), treatment (pharmacological, surgical and
rehabilitative) and outcome (cure or disability) (Mehta 2011).
Psychiatry is the branch of biomedicine that specialises in the treatment of mental illness. A person
is diagnosed by a psychiatrist according to the way in which the symptoms, which are reported by the
person and/or observed by the psychiatrist, fit a set of predetermined criteria (e.g. DSM‐5 or ICD‐11).
Diagnoses range in type and degree of severity, and can include depression, anxiety, substance use dis-
order, psychosis, schizophrenia and dementia. Upon diagnosis, the person is prescribed medication and
often advised to participate in one or more of the psychological therapies. If appropriate, electroconvul-
sive therapy may also be recommended. Once the person responds to this treatment regimen, they are
discharged from care.
The dominance of the biomedical model in the field of mental health has given rise to terminology
that is likewise dominated by notions of disease or pathology. Consequently, the concepts of health and
wellness often take second place to those of ‘disorder’, ‘dysfunction’, ‘illness’, ‘deviancy’ or ‘abnor-
mality’. Language used in the mental health setting is also influenced by the legislative frameworks in
place across Australia. For example, the terms ‘mental illness’, ‘mental disorder’ and ‘mental dysfunction’
are defined in different ways, according to the mental health legislation of each of the states and territo-
ries across Australia. This language use creates a degree of tension for health professionals who are com-
mitted to working within a framework of health and wellness, as they find themselves moving between the
notions of health and illness or wellbeing and dysfunction. The contradictory language use also explains
a common misunderstanding, that is, that the term ‘mental health’ now replaces, or is sometimes synony-
mous with, the term ‘mental illness’. Frequent errors in using the term include the following.
• ‘The person has mental health; she is hearing voices’, rather than the more appropriate ‘The person
may have a mental health problem; she is hearing voices’.
• ‘The consumer has been diagnosed with mental health’, rather than the more appropriate ‘The con-
sumer has been diagnosed with a mental illness’.
To maintain their authenticity, health professionals are encouraged to familiarise themselves with the
most appropriate and current usage of relevant terms in the mental health sector. This is important in
light of the substantial power and influence of language in our society today.

The power of language

Various philosophers have discussed how language plays a crucial role in framing, informing, devel-
oping and maintaining social relations (e.g. Fairclough 1989; Foucault 1961; Goffman 1967). Language
shapes or interprets the way people see the world; it is also used to define or describe personal experi-
ences or situations. Language has the power to persuade, control and even manipulate the way people
think, act and react (Leventhal 2016).
For these reasons, language must be used carefully. When working within a health and wellness frame-
work, one of the core aims of the health professional is to inspire hope in others (Sælør et al. 2015). This
includes helping a person to focus on their strengths and abilities, rather than their deficiencies or dis-
abilities. One way to inspire hope is to employ language that empowers rather than disempowers. This
often requires health professionals to make the conscious choice to use one word over another.
For example, it is generally understood that the word ‘patient’, in the health context, signifies a person
who is being attended to by a health professional. This is because the word has a long history of associa-
tion with medical practitioners and hospitals. Notions of ‘patient’ have also been connected with ideas of

6 Mental health care

11
 passivity (i.e. a patient is a diseased or disabled person who is being treated by an active and expert health
professional). In this way, the word ‘patient’ sets up ideas of disempowerment, with health professionals
positioning themselves as authorities and the patients taking a more subordinate role. It is this unequal rela-
tionship that has led to the development of alternative terms, including ‘client’, ‘consumer’, ‘service user’ or,
quite simply, ‘person’, when referring to individuals who seek assistance from a health professional.
In this text, the word ‘person’ is the preferred signifier for someone who is being cared for by a health
professional. This choice was made because the word serves to normalise the process of giving and
receiving help or assistance. At other times, the terms ‘patient’, ‘consumer’, ‘service user’ or ‘client’ are
also used. This is because people in the clinical context who require assistance for physical or mental
health issues are referred to in a variety of ways, therefore use of the different terms in this text reflects
the clinical context.
Similarly, health professionals are referred to in a number of different ways throughout the text.
The term ‘health professional’ has already been defined. Other similar terms employed in this text
may include ‘clinician’, ‘health care professional’, ‘personnel’, ‘practitioner’, ‘staff member’ or, again,
‘person’. Use of a variety of names reflects the diversity in our health system. It also reflects a desire to
be inclusive and avoid labels.
Indeed, health professionals are encouraged to examine the way in which language can be utilised to
label or stereotype people. Such stereotypes are often derived from misperceptions or ‘myths’ about a
particular (often minority) group of people. For people with a mental illness, the most common myths
that health professionals will encounter in Australian society are outlined in table 1.1.

TABLE 1.1 Myths about mental illness

Myth: mental illness is a life sentence

Facts
• There are many different kinds of interventions available to support people with mental health problems.
Some of these interventions involve medications; others focus more on helping the person to address the
psychological and social issues they may be experiencing.
• The earlier a person receives help for a mental health problem, the better their outcomes.
• There is no reason why people with mental health problems cannot live full and productive lives.
• Many people experiencing mental health problems delay seeking help because they fear stigma and
discrimination. Reducing stigma will encourage more people to seek help early.
• Most people with mental health problems are treated in the community by their general practitioners (GPs).

Myth: mental illnesses are all the same

Facts
• There are many different mental health problems, each with different symptoms.
• Each mental illness has its own particular set of symptoms, but not every person will experience all of these
symptoms. For example, some people with schizophrenia may hear voices, but others may not.
• Simply knowing a person has a mental illness will not tell you about their own, unique experiences of that
illness.
• Mental health problems are not just ‘psychological’ or ‘all in the mind’. While a mental health problem may
affect a person’s thinking and emotions, it can also have physical effects such as insomnia, weight gain or
loss, increase or loss of energy, chest pain and nausea.

Myth: some cultural groups are more likely than others to experience mental illness

Facts
• Anyone can develop a mental health problem; no one is immune to experiencing a mental illness.
• Many people from culturally and linguistically diverse and refugee backgrounds have experienced torture,
trauma and enormous loss before coming to Australia. These experiences can cause significant psychological
distress, which predisposes these people to develop mental health problems.
• Cultural background affects how people experience mental health problems and also how they understand
and interpret their symptoms.

CHAPTER 1 Mental health care in Australia 7

12
 TABLE 1.1 (continued)

Myth: people with a mental illness are violent

Facts
• Research indicates that people who receive treatment for a mental illness are no more violent or dangerous
than the general population.
• People living with a mental illness are more likely to be victims of violence (especially self‐harm). It has been
calculated that the lifetime risk of someone with an illness such as schizophrenia seriously harming or killing
another person is only 0.005 per cent, while the risk of that person harming themselves is nearly 10 per cent.
• There does seem to be a weak statistical association between mental illness and violence. This assertion is
concentrated in certain subgroups, for example, people not receiving treatment who already have a history
of violence, and people with substance abuse issues. However, the association between mental illness and
violence is still weaker than the association between violence and alcohol abuse in general, or between
violence and being a young male between 15 and 25 years of age.

Source: Adapted from Hunter Institute of Mental Health (2014)

In the field of mental health, stereotyping or labelling can have quite negative consequences. It is
important, then, to acknowledge that those who experience symptoms of mental illness are people
first, and their symptoms or conditions are of secondary importance. Outdated descriptors such as
‘schizophrenic’, ‘the mentally ill’, ‘mentally ill person’ or ‘mental institution’ are viewed as unhelpful,
even counterproductive. Instead, health professionals are encouraged to use language such as:
• a person who is experiencing symptoms of schizophrenia
• a person with schizophrenia or living with schizophrenia
• a person who is receiving help for their mental health issue
• a mental health facility or unit.
Fostering the use of constructive language is one way that health professionals can help to manage the
stigma that is experienced by people with mental health issues. Stigma and its outcomes are the focus of
the next section of this text.

1.2 Stigma
LEARNING OBJECTIVE 1.2 Describe the effects of stigma on people with mental health problems.
Seminal philosopher Goffman (1967) defined social stigma as the social disapproval, overt or covert, of per-
sonal characteristics, beliefs, behaviours, or conditions that are perceived by a society to be at odds with
social or cultural norms. Stigma is a social reality that works to discriminate between those who are accepted
as ‘insiders’ and those who are rejected as ‘outsiders’ (Webster 2012). Stigma makes a clear distinction
between ‘us’ as ‘normal’ and ‘them’ as ‘deviant’ — with the latter marginalised or ostracised accordingly.
There are many examples of groups that have experienced social stigma over the centuries. These
examples include those who belong to a minority cultural group or ethnicity, have diverse sexual prefer-
ences or expressions of gender, or have a mental illness or a disability (Carman, Corboz & Dowsett 2012).
Other examples of social difference that can lead to social marginalisation include contagious or trans-
mittable diseases (e.g. leprosy, HIV/AIDS), a criminal conviction, an unemployed status, an eating dis-
order or an addiction to alcohol or illicit drugs (Mannarini & Boffo 2015; Thomas & Staiger 2012).
There is evidence globally that some progress has been made to reduce stigma and change the ways
in which people who experience symptoms of mental illness are perceived (Meier et al. 2015). These
changes are partly due to developments in pharmacology, together with other treatment interventions
that have brought about a marked improvement in outcomes for people who experience symptoms of
mental illness. Changed attitudes have been achieved through the progress made by the global human
rights movement and evolving socio‐cultural perceptions of how minority groups should be treated. In
Australia, improved community perceptions have resulted from work that has been undertaken by pri-
mary health care organisations such as beyondblue, SANE Australia, and the headspace National Youth

8 Mental health care

13
 Mental Health Foundation. The roles of these community managed organisations include supporting
people with mental health issues to live in the community, while also educating the community about
mental illness. (The chapter that focuses on mental health service delivery has further information.)
Although such progress and associated community initiatives are to be commended, there is always
room for improvement. For example, Buys, Roberto, Miller, and Blieszner (2008) suggest that depression
caused by physical pain or illness is more socially acceptable in Australia than depression resulting from
emotional concerns. Similarly, depression is a more acceptable diagnosis than psychosis (Reavley & Jorm
2011). Questions also remain about the community perceptions of people who experience symptoms of psy-
chosis, especially when linked to the misuse of illicit drugs and alcohol. Questions to consider include: is
it more acceptable in Australia to be diagnosed with a psychosis of an unspecified origin or a drug‐induced
psychosis? Health professionals are wise to reflect upon such questions in light of their clinical practice.

Community attitudes
People with mental health problems continue to be stigmatised in and by the community through their
misrepresentation in the news and entertainment media (Whitley & Berry 2013). Perhaps most con-
cerning is the suggestion that people with a mental illness are the main perpetrators of violent crime in our
community. As already noted, this is a representation that is statistically inaccurate (Hodgins et al. 2011;
Short et al. 2013). Vendsborg, Nordentoft, and Lindhardt (2011) argue that the major determinants of
violence are socio‐demographic and economic, with substance abuse the most significant indicator. Yet,
people with a mental illness continue to be caricatured as, for example, a maniac on a killing spree, a
free‐spirited rebel, a narcissistic parasite, or victims of mind games played by psychopaths (e.g. Psycho,
One Flew Over the Cuckoo’s Nest, Silence of the Lambs, Shutter Island) (Ramchandani 2012; TNS
Research International 2010). Certainly there are exceptions to such representations. For example, in the
movie A Beautiful Mind, a man with a serious mental illness is portrayed quite sympathetically. Signif-
icantly however, a feature of this and similar movies is that the protagonists have genius‐like attributes
in addition to their mental illness, thereby suggesting that mental illness is acceptable only if the person
has other exceptional qualities to compensate for the mental illness.
Media representations reflect and also perpetuate community values and attitudes: journalists construct
the community in a particular way, and community members generally understand media representations
as ‘the way things are’ (Dale et al. 2014). This has significant ramifications for people with a mental ill-
ness. For example, misrepresentations work to dehumanise, marginalise and isolate people with mental
health issues. Although changes in community attitudes are evident, it would seem the fundamental
problem remains — people with mental health issues continue to be stigmatised by the community.

IN PRACTICE

Stigmawatch: keeping an eye on

the media
SANE Australia is a national charity working for
a better life for people affected by mental illness,
through campaigning, education and research.
SANE’s StigmaWatch program ([Link]/
stigmawatch) responds to community concern
about media stories, advertisements and other
representations that may stigmatise people with
mental illness or inadvertently promote self‐harm or
suicide. StigmaWatch also provides positive feed-
back to the media where they have produced accu-
rate and responsible portrayals of mental illness
and suicide.

CHAPTER 1 Mental health care in Australia 9

14
 StigmaWatch follows up on reports submitted by hundreds of ‘StigmaWatchers’ — ordinary
Australians, people with mental health problems and their families, health professionals — who are con-
cerned about how the media depict mental illness and suicide.
StigmaWatch reviews these reports against the guidelines developed by the Australian Government’s
Mindframe National Media Initiative. Should StigmaWatch find that a media story is stigmatising, inac-
curate or irresponsible, it will raise these concerns with the media outlet or journalist responsible and
encourage them to revise or withdraw the article. StigmaWatch also provides advice on how to safe-
guard against future media coverage that may stigmatise mental illness and suicide. This is essential
in light of the changing media landscape, including online resource and entertainment, social media
channels.

QUESTIONS
1. The terms ‘fruitcake’, ‘nutter’ or ‘psycho’ are often used colloquially to describe people who experience
mental health problems. Discuss the effects of such labels on people with mental illness, their families,
and also on communities as a whole.
2. Over the next week, record the number of times that you hear family members, partners, friends,
colleagues, or people in the community, on television or in films use words with a negative connotation
to describe mental illness. As a health professional, what can you do to discourage this kind of
communication?

The impact of the stigma associated with mental illness is considerable — it includes reduced options
for employment, obtaining accommodation, and socialising, as well as personal distress and low self‐
esteem (Evans‐Lacko et al. 2013). Self‐stigma is also a problem. For example, people with mental health
issues may sometimes view themselves in a negative light. This results in diminished self‐esteem and
self‐efficacy (Thornicroft et al. 2012). Additionally, stigma may lead to people with symptoms of mental
illness feeling reluctant to disclose their symptoms and/or postponing seeking help.
As a means of supporting the reduction of stigmatising attitudes in our community, the Australian gov-
ernment has legislated to protect the rights of minority groups. When stigma is acted upon and a person
is treated differently because they have a mental illness or other disability, they are experiencing dis-
crimination. In Australia, such discrimination is unlawful under the Disability Discrimination Act 1992
(DDA). According to Webber et al. (2013), discrimination against people with a mental illness is one of
the biggest obstacles to people receiving effective care and treatment. Health professionals are encour-
aged to familiarise themselves with the DDA and model the principles it upholds. This is an important
means by which prevailing community attitudes can be challenged.
Indeed, health professionals are in a prime position to assist with the process of bringing about change.
This suggests the importance of health professionals understanding the impact of social stigma on the
life of a person, including their level of education, employment, income, housing, community involve-
ment and, ultimately, health. By speaking out against stigma, educating the community and advocating
for the person with mental health issues, health professionals can assist to break down the barriers.
These barriers include the stigma that is evident within the health professions themselves.

Attitudes of health professionals

Sadly, the negative attitudes towards people who experience symptoms of mental illness are also evident
within the health professions (Reavley et al. 2014). For example, notions of ‘guilt by association’ often
mean that mental health professionals experience stigma (Verhaeghe & Bracke 2012). Negative attitudes
are expressed by other health professionals through expressions such as ‘I could never work in mental
health!’, ‘Everyone who works in the field of mental health gets assaulted!’, ‘You have to be mad to
work in mental health’ or ‘Don’t go and work in mental health, you’ll lose your clinical skills!’ Such
comments are based on stereotypes rather than research evidence. Moreover, the comments provide one

10 Mental health care

15
 possible reason for the difficulty experienced nationally in recruiting health professionals to work in the
field of mental health (Kopera et al. 2015).
Also alarming are the attitudes and behaviours of a small number of health professionals when inter-
acting directly with people with a mental illness. Some of these attitudes and behaviours have been
identified as:
• talking about consumers rather than to consumers
• putting down and ridiculing consumers
• failing to provide information to consumers to enable them to make informed decisions
• failing to provide appropriate or respectful services
• failing to respect the information shared with the service by family members
• perpetuating negative stereotypes (Hansson et al. 2013; Kopera et al. 2015).
Significantly, these attitudes and behaviours are not confined to the Australian context; they are evi-
dent in countries across the globe and encompass a range of health professions, including medical
practitioners, nurses, allied health professionals and students (Chien, Yeung & Chan 2012; Hansson
et al. 2013).
In light of this situation, it is essential that health professionals understand the issues involved, in
particular the way in which stigmatising attitudes and behaviours influence the empowerment and
disempowerment of people with mental illness (Ryan, Baumann & Griffiths 2012). Specifically, the
research evidence suggests that many health professionals feel threatened or challenged by notions of
empowerment for consumers (O’Reilly, Bell & Chen 2012). This includes health professionals taking
actions such as:
• removing the personal freedoms of the person with a mental health problem
• forcing people with a mental illness to take medication against their will
• deciding which aspects of treatment and care will or will not be provided to the person without con-
sulting them
• making decisions about a person’s ‘best interests’ without consulting them
• using language and terminology that alienates or excludes the person who is experiencing symptoms
of mental illness (Barrenger, Stanhope & Atterbury 2015; Sweeney et al. 2015).
There is a need, then, for each and every health professional to take responsibility, self‐examine,
and identify their personal attitudes towards, or perceptions of, people with mental health problems.
This process of self‐examination or self‐reflection must include consideration of the value placed by
people with mental illness on health professionals who take non‐paternalistic, respectful and inclusive
approaches (Valenti et al. 2014). There is also a need to:
• consider the unique situation of each consumer
• be aware of the insidious, even seductive nature of the power that can be wielded by health pro-
fessionals over vulnerable people, including those who are unwell
• adapt and adjust professional responses to people with a mental illness based on the insights gained.
Questions health professionals may ask themselves as they reflect could include, ‘How do I view
people with a mental illness?’ and ‘How do these attitudes and perceptions impact upon my professional
practice?’ Answering these questions honestly will assist the health professional to become a practitioner
with high levels of self‐awareness.
Indeed, fostering self‐awareness is necessary for all health professionals. It is only through self‐
awareness that health professionals can address issues that may impede their capacity to:
• build and maintain an effective therapeutic alliance or relationship
• collaborate with consumers and their carer or families
• support the development of coping strategies for people with mental health issues
• facilitate the Recovery journey and best possible long‐term outcomes for mental health consumers.
Acquiring the skills to self‐reflect and foster self‐awareness will, in turn, enable health pro-
fessionals to more effectively assist the many people in Australia who experience symptoms of
mental illness.

CHAPTER 1 Mental health care in Australia 11

16
 UPON REFLECTION

Reflective practice
Reflection is the examination of thoughts and actions. Health professionals can reflect on their practice
by focusing on how they interact with their colleagues and the environment in which they work. Reflec-
tive practice is a process by which health professionals can become more self‐aware, build on their
strengths, work on their weaknesses and take action to change the future. Health professionals from a
range of disciplines participate in reflective practice, including allied health, first responders, midwives
and nurses (Oelofsen 2012; Turner 2015).

QUESTIONS
1. Reflection‐in‐action involves considering events that have occurred in the past. Identify an event in
which you were involved where a person with a mental illness was stigmatised. What could you have
done differently?
2. Reflection‐in‐action involves considering events, including your own behaviour(s) and the behaviour
of others, as they occur. What techniques could you use, as a health professional, to develop
reflection‐in‐action?
3. Critical reflection involves uncovering our assumptions about ourselves, other people, and the
workplace. What techniques could you use to critically reflect on your assumptions and attitudes
towards people with a mental illness?

1.3 A focus on caring

LEARNING OBJECTIVE 1.3 Discuss notions of ‘care’ and ‘caring’.
In light of a context that is characterised by negative attitudes towards people with a mental illness, as a
health professional, what does it mean to ‘care’? With the many advancements that have been made in
science and technology, as well as research and evidence‐based practice, is ‘caring’ a construct that is
relevant to the delivery of health services today? These are important questions for health professionals
to consider, with the delivery of health care in Australia is driven by a demand to meet key performance
indicators (KPIs) and collect empirical data to inform evidence‐based practice (Nowak 2012; Shields
2012). In this context, ideas of care and caring can sometimes be forgotten.
Interestingly, precise definitions of the terms ‘care’ and ‘caring’ are lacking in the health context. For
example, care is both a noun and a verb — it is a feeling or attitude, such as concern; and it involves
action or activity, such as attending to a person (Ranheim, Kärner & Berterö 2012). Care can be under-
stood as a way of being and also a way of behaving (Leininger 2012a). Despite these differences, it is
often presumed that an understanding of the notion of caring ‘comes naturally’ to health professionals
(Alpers, Jarrell & Wotring 2013). For example, by virtue of choosing to work in the field of health,
a health professional may be described as a caring person. However, the nature of health care in the
twenty‐first century means that health professionals will practise, intervene, treat, manage, assist and
support, engage in therapy or deliver a service (Hogan & Cleary 2013). Efficiency and effectiveness are
the name of the game. This raises the question: where does care and caring fit? Answers to this question
in part lie with the history of caring.

History of caring
Different disciplines have developed different knowledge bases to explain what it means to provide care.
For example, health professionals who work in the field of nursing have a long tradition of providing
care, developed from the work undertaken as far back as Florence Nightingale in the mid‐1800s. Caring
theorists Peplau (1952, 1991) and more recently Barker (2009) have built on this work, describing the
notion of caring as both a science and an art; that is, caring comprises a set of evidence-based technical
skills as well as personal qualities such as sensitivity, giving respect and accepting others.

12 Mental health care

17
 From a multidisciplinary perspective, the seminal philosopher Heidegger (1962) described ‘caring’
as a universal phenomenon that influences the way people think, feel and behave in relation to one
another. Almost 20 years later, in the health context, commentators such as Ray (1981) identified four
ways of thinking about ‘caring’:
1. psychological care
2. practical care
3. interactional care
4. philosophical care.
In so doing, the notion of care is constructed as both a theoretical framework and an approach that is
taken by health professionals to improve the levels of a person’s physical and mental health, as well as
their ability to function on a day‐to‐day basis.
A decade later, Morse, Bottorff, Anderson, O’Brien and Solberg (1991) went on to suggest five cate-
gories of caring:
1. a human trait
2. a moral imperative
3. an effect or outcome
4. an interpersonal interaction
5. a therapeutic intervention.
This view of caring suggests much more than the demonstration of concern for a person or even
attending to that person. It is a view that also involves knowledge, thinking, planning, implementation
and evidence of effectiveness. At the same time, the categories of interpersonal interaction and thera-
peutic intervention suggest that caring has a very personal focus.
It is perhaps for this reason that Dyson (1996) linked caring to the personal qualities of knowing,
patience, honesty, trust, humility, hope and courage. Watson (1988) likewise conceptualised care and
caring as an interpersonal process between two people that protects, enhances and preserves the dignity
of the person; and enables the survival, development, and growth of all those involved. Caring, then, is a
construct that is both theoretical and practical, as well as procedural and personal.
Of particular importance is the difference noted by Leininger (1981) between general or generic
caring and professional caring. General or generic caring is learned as part of a person’s ongoing
growth and development, by way of upbringing, family background, cultural values and life experiences.
Professional caring has a more conscious and comprehensive focus, and encompasses each of the dif-
ferent dimensions of personhood. For example, health professionals care for a person’s physical and
mental health, as well as their social, spiritual and emotional wellbeing.
This view has been supported by other researchers across the years. Of particular importance are sugges-
tions that, while feelings of concern and the act of attending to a person hold a significant place in the delivery
of health services, they are unlikely to be therapeutic unless the person providing the care is competent or
proficient (Barker & Reynolds 1994; Leininger 2012b). For health professionals, then, health care and caring
involves specific knowledge and skills, as well as attitudes and action. This is because proficient and pro-
fessional care and caring has a context and purpose: supporting better health outcomes for all.

Aims of care and caring

In the broad sense, the aim of all health care is to improve health outcomes (World Health Organization
1986). More specifically, in Australia an important aim of delivering a mental health service is consumer
participation. This aim is in line with national strategic direction (Commonwealth of Australia 2005,
2009); and also with the growing influence of the consumer movement (Hunt & Resnick 2015; Adams &
O’Hagan 2012).
Care and caring in the professional sense will always be influenced by the aims of its delivery, and
these aims will depend upon the context of the care and caring. The health care context is complex
and comprises many relational and environmental factors (Dewar & Nolan 2013; Ranheim, Kärner &
Berterö 2012). This includes the structures and settings created by the organisation that is providing the

CHAPTER 1 Mental health care in Australia 13

18
service, the type of service delivery, the knowledge base and approach of the health professional pro-
viding the service, together with the needs and preferences of the person(s) receiving the care (Wright &
Chokwe 2012).
In turn, each of these contextual aspects is multifaceted. For example, the context of the person who is
receiving care will comprise many aspects of personhood including the behavioural, biological, cultural,
educational, emotional, environmental, financial, functional, mental, occupational, physical, recreational,
sexual, spiritual and social. Consequently, health professionals must change or adapt their practice to
meet the very specific needs and preferences of each of the people they help. This suggests why there is
no one‐size‐fits‐all approach to the delivery of care. Rather, the type of care delivered must be flexible
enough to fit the needs and preferences of the person it serves.

Definitions of ‘care’ and ‘caring’

In light of the history, context and purposes of delivering health care, in this text the terms ‘care’ and
‘caring’ are understood as a collaborative process that occurs between health professionals and a person
or persons to achieve mutually agreed upon objectives. Care and caring are delivered in a systematic way
by health services to support people and improve health outcomes. Care and caring is also an attitude
and set of actions demonstrated by competent health professionals in the course of their work (Alpers
et al. 2013; Holttum 2015). The best health care and caring is consumer‐centred and person‐focused;
that is, it is delivered according to each person’s individual needs, preferences and choices.
Interestingly, research has identified a marked difference between the activities that consumers
identify as the most important to them when they receive care, and the activities that health professionals
identify as the most important for consumers (Leininger 2012a; Suserud et al. 2013). For example, con-
sumers often report that they remember the kindness exhibited by a health professional, while health
professionals tend to be more focused on providing effective clinical interventions as efficiently as poss-
ible. These differences suggest that consumers must always be given the opportunity by the health pro-
fessional to express their preferences and make their own choices. Further, and as much as is possible
within the health service framework, health professionals must work towards supporting these pref-
erences. This is why care is often described as a process that is negotiated between the consumer and
the health professional in a process that involves caring with as well as caring for the person (Hogan &
Cleary 2013).
In any definition of care, the related competencies of the health professional must also be identified.
When helping the person with a mental health problem, these competencies include specific knowledge,
clinical skills and communication skills to:
• engage with the person
• actively listen to the person
• build a relationship with the person.
Further, care requires health professionals to demonstrate an attitude of compassion and sensitivity,
a giving of self, as well as honesty and sincerity (Coffey, Pryjmachuk & Duxbury 2015; Dewar &
Nolan 2013). While these attributes are very personal, it should also be noted that, for the health pro-
fessional, they do not necessarily ‘come naturally’ in the workplace. Rather, health professionals must
develop themselves professionally so that they can provide care regardless of their reactions to a person
or situation. More detailed information on how the health professional can manage their reactions and
emotions in challenging situations is provided in the chapters focusing on common reactions to stressful
conditions, and people displaying challenging behaviours.
Finally, while there is no doubt that technology is important to the delivery of health services in
Australia today, it is the health care itself that ensures the humanity of these health services. Essentially,
it is in the very nature of people to care for others in need. Perhaps most profoundly, when competent
care and caring is delivered and people connect to and with one another, the health outcomes will speak
for themselves (Leininger 2012b). These outcomes will include an improved social and emotional well-
being of the people involved.

14 Mental health care

19
 Health professionals must display competency in engaging with the person, actively listening to the person and
building a relationship with the person.

UPON REFLECTION

Care and caring

Reconsider the sentence from the previous section: ‘There is a marked difference between the activities
that consumers identify as the most important to them when they receive care, and the activities that
health professionals identify as the most important for consumers.’

QUESTIONS
1. Why do so many health professionals think that they ‘know better’ than the person who receives the
care?
2. What is the difference between the knowledge gained through university study and the understanding
gained from the lived experience of a health condition?
3. How can health professionals bridge the perceived divide between theory and lived experience of a
mental health problem, to support the notions of individual choice and preference?

1.4 Caring in the health context

LEARNING OBJECTIVE 1.4 Explain the context of care in Australia.
All health professionals can learn from the way in which mental health care has been provided over the
years. In particular, there are quite profound lessons to learn from the many errors that have been made
when delivering services, both past and present.

CHAPTER 1 Mental health care in Australia 15

20
 In early colonial times, people with a mental illness were locked away from the community in ‘lunatic’
asylums. The first ‘mental institution’ in Australia was located at Castle Hill, New South Wales, from
1811 to 1825 (Evans 2013). Prior to this, ‘the insane’ were housed at either Parramatta Gaol or, in some
cases, Bedlam Point at Gladesville. Other asylums were established in each of the new colonies, around
Australia, in the years that followed (Colborne & MacKinnon 2003).
At that time, endeavours were made to provide humane treatment and there were numerous com-
missions and inquiries into reported abuses. Even so, overcrowding in institutions across Australia
meant that a predominantly custodial approach was taken to provide care of those who were ‘com-
mitted’. As a result, treatment options were limited (Evans 2013). Moreover, the focus of the treat-
ment options was often physical in nature and included straitjackets and cold baths (Coleborne &
Mackinnon 2006).
It was only after the Second World War that scientific advancement gave rise to new pharmacological
interventions that enabled better outcomes for people with a mental illness (Beer 2009). In turn, with
improved knowledge and better outcomes, came changes in the way people and societies viewed mental
health and mental illness. This included recognition that people with mental health issues had the right
to live freely in the community, and that the previously common practice of locking people away from
mainstream society, with no right of reply, was unethical.
In response, governments across the Western world began to examine the way in which health care
was delivered to people with a mental illness. In Australia, the inquiries and reports that were most influ-
ential in questioning the ethics and practices of the day included the:
• Richmond Report (1983)
• Barclay Report (1988)
• Burdekin, Guilfoyle, and Hall Report (1993).
Detailed information about these reports can be found on the websites of relevant state and territory
departments of health, or the University of Sydney Index of Australian Parliamentary Reports.
The implementation of recommendations made by these and similar reports and inquiries gave rise to
huge changes to the way mental health care was delivered in Australia. These changes have included:
• the deinstitutionalisation of mental health services
• a decrease in the size and number of psychiatric hospitals
• the separation of developmental disability services from mental health services
• support for consumers to live in the community
• the development and expansion of integrated community services or networks, including health ser-
vices, accommodation services, and other social services
• changes in funding arrangements to support the new era in mental health service delivery (Hillingdon
2011; Loi & Hassett 2011).
The profound impact of these changes continues to be felt by many health professionals and services
in all states and territories, across Australia.
The process of deinstitutionalisation also saw the development and implementation of new mental
health legislation in Australian states and territories. While there are clear differences in the way in
which this legislation is enacted in each of the states and territories, the fundamental principles are the
same. These include:
• protecting the human rights of people with mental health problems
• guarding the safety of people with mental health problems, and also the safety of the community
• ensuring that people with mental health problems are treated in the least restrictive environment
• promoting individual choice of lifestyle for consumers.
By upholding these principles, health professionals will effectively support the spirit of the legislation
regardless of location.
At this point it is also helpful to note that, in line with the development of mental health legis-
lation, each of the states and territories has also developed their own legal frameworks to protect
the rights of people with disabilities (McSherry & Wilson 2015). Although this legislation was and

16 Mental health care

21
 continues to be distinct from mental health legislation, it reflects many of the same principles and
ethical principles. The various types of health services available for people with a mental illness
and intellectual disability are outlined in the chapter focusing on mental health service delivery. In
addition, health professionals are encouraged to seek out information on this important aspect of
health service delivery, especially as people with a disability have a higher incidence of mental ill-
ness than the general population.
The advent of deinstitutionalisation also saw the development and implementation of new models of
care and treatment for people with a mental illness. This included mainstreaming, which was intro-
duced as a means of reducing the health inequalities and stigma experienced by people with mental
health issues. Today, people who present to health services with symptoms of mental illness are no
longer sent to separate campuses at ‘other’ locations. Instead, mental health services have been inte-
grated into the general or mainstream health system (AIHW 2016b; Martens 2010).
Not only that, the traditional custodial function of those who treated or cared for people with mental
health issues has now been replaced by a therapeutic function. Today, it is the role of health professionals
to enable consumers to live in the community and be contributing members of that community. To do
this, health professionals work with other government departments and agencies, such as social and
housing services, to facilitate care that is comprehensive and integrated, and encompasses all aspects of
the person’s life.

UPON REFLECTION

Deinstitutionalisation
Some people suggest that the widespread closure of the mental health asylums or institutions in
Australia created more problems than it solved. This is because many people who had previously lived
in institutions — where they were provided with food, clothes and a roof over their head — became
homeless when those institutions were closed. Also of concern are statistics that indicate almost half
of prison entrants (49 per cent) report that they have been told by a health professional that they have
a mental health disorder, and more than one in four (27 per cent) are currently on medication for a
mental health disorder (AIHW 2015b). Some commentators suggest prisons have becomes ‘the new
institutions’ of the twenty‐first century.

QUESTIONS
1. What do you see as the benefits of deinstitutionalisation for people with mental illness, which
commenced in the 1980s?
2. What do you see are the challenges of deinstitutionalisation?
3. How would you respond to those who call prisons ‘the new institutions’ of the twenty‐first century
for people with a mental illness?

Current policy directions

Mental health policy in Australia today, at the national and state or territory levels, has developed over
time and in response to directives from the United Nations and the World Health Organization (WHO).
Also important has been the ongoing lobbying of governments by human rights groups and members of
the consumer movement.
In 1991, the United Nations (UN) established the Principles for the Protection of Persons with Mental
Illness and the Improvement of Mental Health Care. This document commences with a statement
upholding the fundamental freedoms and basic rights of those who experience symptoms of mental ill-
ness. The remaining 24 principles provide guidance on how these freedoms and rights are upheld. They
include enabling people with mental health problems to live in the community; and also ensuring that
care is readily accessible, has the least number of restrictions on the person’s freedom and rights, and is
appropriate for the particular needs and preferences of the person.

CHAPTER 1 Mental health care in Australia 17

22
 In 2009, Australia was reviewed by the UN Special Rapporteur for its human rights performance, as
part of a regular process that occurs for all member states of the UN. The Human Rights Council made
over a hundred recommendations to the Australian government for change, including those related to
the way in which people with mental illness were treated. For example, it was recommended that the
Australian government:
• allocate adequate resources for mental health services and other support measures for persons with
mental health problems, in line with the United Nations Principles for the Protection of Persons with
Mental Illness and the Improvement of Mental Health Care
• reduce the high rate of incarceration of people with mental illness
• ensure that all prisoners receive an adequate and appropriate mental health treatment when needed
(Human Rights Law Centre 2011).
Today, many of these recommendations have been implemented, thereby ensuring that the way in
which Australia delivers mental health services is better aligned to the framework provided by the UN.
No less important is the guidance provided by WHO. Of particular importance is the recommendation
that all mental health policies be anchored by the four guiding principles of:
1. access
2. equity
3. effectiveness
4. efficiency (World Health Organization 2001).
Services that are accessible allow all people to seek treatment sooner rather than later. In Australia,
providing accessible as well as equitable services can be challenging when considered in light of the
cultural and linguistic diversity of the population, together with the vast distances between many rural
and remote communities (Veitch et al. 2012). Even so, access and equity remains two of a number of
cornerstones of mental health service delivery in Australia today. Indeed, Australians pride themselves
on the fact that quality mental health services are made available to all, regardless of distance, cultural
background, religion, or ability of the person to pay.
Likewise, the Australian government of today is committed to delivering appropriate, timely, effec-
tive and efficient mental health care that is in line with the best available, contemporary, evidence‐based
research (National Health and Hospitals Reform Committee 2009). Services must be comprehensive
and integrated; and facilitate the timely treatment of those who are in need of help (Petrakas et al. 2011;
Rosen & O’Halloran 2014). As with access and equity, effectiveness and efficiency are core tenets that
guide the delivery of all health services in Australia, including mental health services.
Since the early 1990s, the national and state or territory governments have developed a range of
mental health strategies, plans and policies to reflect UN and WHO principles and recommendations.
For example, the National Mental Health Strategy provides direction to state and territory governments
across Australia to enable improvement in the quality of life of people living with symptoms of mental
illness. This strategy was first endorsed in April 1992 by the Australian Health Ministers’ Conference
(1992a 1992b) as a framework to guide mental health reform.
According to the Department of Health website ([Link]), the National Mental Health
Strategy aims to:
• promote the mental health of the Australian community
• prevent the development of mental health problems
• reduce the impact of mental health problems on individuals, families and the community
• assure the rights of people with a mental illness.
Milestones for the development of the National Mental Health Strategy are outlined in the various
documents that mark the evolution of the National Mental Health Strategy. These include the:
• National Mental Health Policy (1992, 2008)
• National Mental Health Plan(s) (1992–1997, 1998–2003, 2003–2008, 2009–2014)
• National Mental Health Standards (2010)
• Mental Health: Statements of Rights and Responsibilities (1991, 2012)

18 Mental health care

23
 • National Roadmap for National Mental Health Reform (2012–2022)
• Establishment of the National Mental Health Commission (2012)
• Contributing Lives, Thriving Communities — Report of the National Review of Mental Health Pro-
grammes and Services (2014)
• Australian health care agreements.
The National Mental Health Strategy and ongoing developments have great significance for all health
professionals across Australia. Regardless of the location or context of their work, health professionals
have a responsibility to familiarise themselves with, and abide by, the principles and policies outlined
in the strategy. To support health professionals to familiarise themselves with these process, an A–Z
listing of mental health publications can be found at the Commonwealth Department of Health website
([Link]).

Current service frameworks

It is important that health professionals understand the frameworks within which they provide health care.
Such understanding enables health professionals to see the ‘big picture’ of their everyday work. This sec-
tion provides a brief overview of the principles that guide the delivery of health care in Australia. This
information will help health professionals to contextualise the information provided throughout this text.
Significantly, the overarching framework within which health care is delivered to people with mental
health issues in Australia is the same as that which guides all health care and treatment. This framework
is called the public health framework or approach.
Public health framework
The ‘big picture’ framework for health service delivery in Australia is called ‘public health’. This term
is not to be confused with the public health care system, which includes Medicare and other health
funding that supports the universal health coverage provided to all Australians and permanent resi-
dents. Rather, by examining the health trends in populations, communities or groups, and recommending
or overseeing appropriate interventions, the public health framework in Australia aims to:
• prevent disease
• promote good health practices
• prolong life.
Public health includes epidemiology, which is the study of patterns of health and illness in populations
or groups, and involves statistical analysis of data generated to provide an evidence base that shapes stra-
tegic direction (Putland et al. 2013). Some health professionals would know this approach as ‘population
health’, which identifies groups of people that are particularly vulnerable to health issues because of
their demographic characteristics (e.g. age or cultural background) or past experiences (e.g. exposure to
trauma or abuse) (Perkins et al. 2011). For example, the statistics cited earlier, in relation to the mental
health status of the Australian population, fall into the population health category, and provide a basis
upon which Australian governments develop strategic direction and shape services (e.g. National Health
and Hospital Reform Committee 2009). The public health framework also incorporates services such
as prevention and promotion, environmental health, occupational health and safety services, and other
services that enable self‐determination, self‐care and self‐help for all communities and people. These
services form an integral part of the Australian primary health care agenda.
Primary health care agenda
Primary health care is an integral part of the public health framework. Primary health care is currently
defined by WHO as:

essential health care made universally accessible to individuals and families in the community by means
acceptable to them, through their full participation and at a cost that the community and country can
afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the
overall social and economic development of the community (WHO 1978).

CHAPTER 1 Mental health care in Australia 19

24
 Primary health care, then, is essential care because it is about supporting people, families and com-
munities (Cleary et al. 2014). It is holistic and comprehensive in approach, incorporating all aspects
of what it means to be human and achieve optimal levels of health (DoHA 2010). Primary health care
focuses on health rather than illness, prevention rather than cure, and communities rather than hospitals
(National Health and Hospitals Reform Committee 2009).
An important aspect of the various primary health care services in Australia is the delivery of resources
and information to promote healthy lifestyles within communities, by communities, and to support
communities (Gwynn et al. 2015). Other areas of focus include equity in health care; research‐based
methods; accessible, acceptable, and affordable technology; promotion of health; prevention of illness;
early intervention; and continuity of care. In short, primary health care is ‘community‐centric’.
Primary care — a subset of primary health care — is accessible, affordable, and enables people or
groups of people to participate individually and/or collectively in the planning and implementation of their
health care (Primary Health Care Working Group 2009). There has been a tendency in Australia to position
‘primary care’ within the biomedical model and the domain of general practitioners who operate out of
small businesses located in the community. Consequently, the term is often construed as meaning the ‘first
point of contact’ in the health care system. However, primary care is much bigger than this. All health pro-
fessionals can provide primary care, regardless of setting, because this type of care enables them to:
• acknowledge diversity in the culture, values and belief systems of the person, while promoting their
dignity as a person and right to self‐determine
• establish collaborative partnerships with the person, together with their family or significant others,
ensuring open channels of communication, and active participation in all aspects of their care
• engage therapeutically with the person, together with their family or significant others, in a way that
is respectful of the person’s choices, experiences and circumstances; building on the strengths of the
person, enhancing the person’s resilience, and promoting health and wellness
• collaboratively plan and provide a variety of health care options to the person (including the coordi-
nation of these options) and ascertain that these options are consistent with the person’s mental,
physical, spiritual, emotional, social, cultural, functional and other needs
• actively value the contributions of other health professionals, health services, agencies and stake-
holders, ensuring the collaborative and coordinated delivery of holistic or comprehensive evidence‐
based health care
• pursue opportunities to participate in health promotion and illness prevention activities with and for
the person, including health education and support of social inclusion and community participation
(DoHA 2010).
It is all too easy for health professionals to overlook the essential role played by primary health
care services, such as prevention and promotion services, because these services tend to be staffed by
the ‘unsung heroes’ who work behind the scenes (Roberts 2012). Similarly, health professionals who
work as first responders or in the very busy secondary health care and tertiary health care sectors
may underrate the important and ongoing health‐related work that is carried out by non‐government or
community managed organisations, or by small medical or allied health practices. This is because these
organisations do not ordinarily provide emergency or acute services. Yet primary health care services
provide an important means by which people, especially those with mental health issues, are supported
to live in the community. Indeed, in Australia, primary health care services play an essential role in
supporting the deinstitutionalisation of the mental health services. More information about the primary
health care agenda, primary care, and the primary health care services that are delivered in Australia, is
provided in the chapter that focuses on mental health service delivery.

Current service approaches

All health systems will take a particular approach to the way they deliver their services, with different
approaches taken at the different levels of health care. For example, one approach may be used when
providing a service to the individual and their family or carers, whereas a different approach may be

20 Mental health care

25
Another Random Scribd Document
with Unrelated Content
foreign newsagency business and was turned into a public company
in 1865 for the purpose of raising sufficient capital to equip a
telegraph cable from England to Germany. This direction of
development was subsequently altered and the cable sold and
Reuter’s name became the trade-mark for semi-official foreign news
all over the world.

Of domestic newsagencies in the United Kingdom there are many

which come and sometimes go without making much stir in the
world. The chief rival of the Press Association and Reuter is the
Central News covering both domestic and foreign intelligence.
Laffan’s service is also international in character and so is the
Agence Havas. The chief domestic rivals of the P.A. are the Exchange
Telegraph Company and the London News Agency, a newcomer
founded by three or four experienced reporters, who found their old
livelihood made by “penny-a-lining” being slowly undermined by the
agencies. At one time these made almost a monopoly of police-court
news in London, but this with other general news now passed
almost completely out of private hands.

In addition there are the specialist agencies, whose names in most

cases proclaim their work, such as the Commercial Press Telegram
Bureau, the American Press Telegram Bureau, the National Press
Agency, the Labour Press Agency, the sporting news services and
firms like Tillotson’s, who do a great business in syndicating popular
fiction for publication by newspapers in feuilleton form. Topical
photographs are also a favourite subject of traffic by agencies for the
benefit of illustrated papers. There is no question that this form of
enterprise is largely on the increase, as the public is agog to have
every sense tickled, as well as to have information as food for the
imagination.

Some of the humbler servants to newspaper production, which

escape the notice of those, who only know the big journals of the
large cities on both sides of the Atlantic, are the agencies, whose
business it is to furnish syndicated matter, supplied at a low price,
not only already written and edited but even set up in print,
stereotyped and ready for the press. Such a commodity passes in
America under the name of “plate matter” and the trade in this
branch of literary wares is enormous, especially there, where the
small local papers cannot rely upon filling more than half their
columns with the real news of their own districts. The organizations
which supply this line of goods, sell the matter at so much a column
or half column with or without illustrations. General news, fiction,
truth, political opinions and jokes are all offered at the same “flat
rate.” It is as near a thing to a Cervelatwurst, sold by the pound or
foot, as one can get in the intellectual world.

There is one field for journalism, which is now peculiarly the

property of the enormously circulated evening press. The halfpenny
evening paper is the daily paper of the working man and especially
so in the provinces, where in the small towns none but evening
newspapers exist. For their immense mass of readers every
conceivable matter of national or personal interest is subordinated to
the overwhelming predominance of games, sports and betting. It is
no exaggeration to say that five-sixths of the circulation of all the
halfpenny evening papers is built up on amusements and gambling.
The two for the most part go hand in hand, because, with the single
exception of cricket, there is hardly any widely extended form of
sport, which, so far as the masses of the people are concerned, is
not the subject, and predominantly the subject, of betting.
Incomparably the keenest competition in the newspaper world is
developed as the result of rivalry to bring out the earliest news of
sporting events. There is no indication of a reversal of this tendency,
but since the mechanical facilities, which provide the means of this
rapid production, are now the common property of all, it is no longer
possible for any one competitor to leave another seriously behind.

The progress and development of these mechanical facilities are

probably a matter of general interest, because, although the results
of this break-neck rivalry are apparent to any man in the street, the
methods, by which it is accomplished, are due to very elaborate
devices of great technical perfection. I do not know that it is a
matter to be inordinately proud of but this form of competition was
first developed to its highest form of excellence, not in America but
in England and not in London, but in the provinces. The old and
common method of bringing out a special edition with the results of
a race was by cutting a hole in the stereoplate from which the paper
was printed and slipping in a small box with a spring, holding one or
two lines of type. The process was dangerous and inadequate
because it would be used only once for one announcement and that
a curtailed one. Mr. Mark Smith of Manchester originally invented the
device now in universal use. His invention is variously called the
“late-news device” the “stop-press box” or familiarly the “fudge.” The
object of this invention was to enable several small items of news,
such as the result of a race or football match or the score at cricket,
to be rapidly inserted in the paper, without the necessity of altering
the body of the text and of going through the lengthy operation of
recasting the large metal stereoplates from which all rapid printing
has to be done. For this purpose a blank of about half a column has
to be left on the main page, or on whichever page is selected for the
latest news, so that, as the paper passes through the printing-press,
that portion remains unprinted. Corresponding with the space thus
left blank, there is attached to the printing-press a small
supplementary cylinder, which can carry securely clamped a specially
designed box to hold type or linotype slugs, so adjusted as to print
on the portion of paper left blank during its passage through the
main press. It is an easy and expeditious task to alter the contents
of this small box without otherwise disarranging the plates and the
process effected a material increase in the pace of production over
the old methods, especially where a large number of presses were
used to produce a big edition. The two to five minutes thus gained
were quite sufficient to establish a decisive advantage over a rival
not similarly equipped for publishing news of special interest. At the
present time hardly any evening paper in any considerable town in
America or the United Kingdom is without this invention.
 At one time this device was protected by a patent, which was the
property of a firm for which I was acting and I came across an
amusing experience in connection with it during one of my visits to
America. Some little time before, while my firm was engaged in
difficult and expensive litigation over the validity of the patent in this
country, there had been some question of the purchase of these
patent rights for New York by the proprietors of the New York X. We
had been asked in the course of this negotiation, whether we would
defend this patent, if infringed. Having our hands more than full with
litigation at the moment we declined, but offered to sell the entire
rights in the invention to the New York paper for a moderate sum.
The New York X broke off negotiations and knowing that the patent
would not be defended adopted the device at once and spent a very
considerable sum of money in adapting their presses for this
purpose. There the matter was dropped for the moment.

Some eighteen months later, when we had successfully

established our own patent here through a decision in the House of
Lords, I had occasion to go to New York and found myself one
evening in the office of the New York X. The occasion was of
exceeding importance to the New York press. It was the night when
the prize-fight to decide the championship of the world was to take
place at Coney Island—a little way out of the city—between Jefferies
and Fitz-Simmons and the island of Manhattan was agog from end
to end with excitement to a degree, which sober Britons would
hardly understand. On that occasion there was especial rivalry
between the two popular papers in New York, the X, in whose office
I was, and the Y. Both had made elaborate arrangements for special
editions and the presses in both offices were furnished with very
expensive installations of the special late news apparatus, which was
controlled by our patent.

Mr. M. the manager of the X received me most cordially and

showed me all over his office and the machine room. When I
reminded him of our unsuccessful negotiation over the patent, he
smiled genially and remarked that it was all right. In introducing me
to various foremen in the building he said, jocosely: “This is Mr. D.,
whose patent we stole,”—the exact phrase was his own. Before
leaving him that night I met him in his own spirit and said in
farewell: “You have spent a lot of money on equipping yourself with
this patent and the Y has done the same. What good has either of
you got out of it? Do you not think it would have been better to have
bought our patents for a moderate sum and have kept out the other
fellow?” He smiled: “Now that you put it that way, perhaps you are
right.” So we said: “Good-night.”
 CHAPTER IV

THE NEWSPAPER AS AN ORGAN OF OPINION

While the necessary characteristic of all periodical literature has been

the conveyance of news of some sort, sometimes of a general and
frequently only of a special character, there has run side by side with
this function the conveyance of general information and of instructed
comment and incidentally the opportunity of thus moulding public
opinion. In respect of this capacity there has been the widest
divergence in the character of newspapers and journals. So far as
they are newsgatherers and news disseminators, all papers have the
same task, even when there are enormous differences of excellence
and subtle differences of intention. But it is otherwise with them as
organs of opinion. This is an optional duty, which a great many
papers avowedly reject. Others by professing impartiality seem to
follow the same policy, while in reality they attempt to exercise
influence by every indirect method. A minority constitute themselves
or find themselves forced into the position of becoming the official or
half-avowed leaders of parties or groups, while every word of
comment or criticism is admittedly stamped with the current
doctrines commonly held by its special band of readers.

It is the case of these latter organs which we have specially to

consider in this chapter. There are so many ways of either guiding or
forming opinion by editorial comment or exposition and by the
publication of signed or unsigned articles of a more or less rhetorical
nature that a complete analysis of the subject means little less than
the history of the press. There are, however, roughly speaking,
certain broad differences of method, which afford us means for a
partial classification. It has been the habit for newspapers on the
continent of Europe to become the mouthpiece of certain well-
known journalists or groups of journalists, who influence and lead
opinion by the publication of signed articles, for whose policy the
individual journalist is himself alone responsible. In the United
Kingdom the prevailing practice has followed another course.
Anonymous journalism has been found in the end to be a more
powerful political weapon, partly because reverence attaches itself
more easily to the unknown and also because the shelter of
corporate responsibility adds somewhat to the freedom of writing
and very much to the fertility of invention. In America again the case
is somewhat different. Both methods are there followed but they are
employed subject to the supreme requisition made by the reading
public for mere news, which it can analyze and judge for itself.

Just as we chose the American daily paper for the model of a

newsgathering and news-presenting organization, so here we must
admit that, as an organ for expressing instructed opinion not only on
politics but on general topics, the distinctively English type of paper
is a far more potent and more highly-developed instrument. In this
respect the American press suffers severely from the general
democratic contempt prevailing on that continent for expert opinion
of all kinds. Since one man there is commonly reputed to be as good
as another, so there is no room even in that huge population for any
one whose opinion carries weight in any other sense than that a
large number of people think that he adequately expresses their
views or comes near to saying publicly, what privately each man
feels and thinks more effectively for himself. Although there are to
be found across the Atlantic many men of literary distinction and of
a culture, which would be exceptional anywhere, they hold sway,
journalistically speaking, only in elegantly printed magazines of small
circulation and in social circles they are notable for an apologetic
manner and deprecatory attitude to their countrymen, which
sometimes seem odd to a stranger prepared to reverence their
talents. Of course here as elsewhere there are exceptions, which we
will come to later on.
 So far as the American press is concerned the only sphere, where
editorial influence is either secretly or forcibly exerted, is in national
or municipal politics. Here the line is so sharply drawn between
opponents that little or no attempt at impartiality is pretended and
news and comment are both frankly presented by party newspapers
with highly-coloured bias and vehement advocacy. Persuasion is not
a weapon adopted by the American press, because during a political
campaign no reader has time or inclination to read the other side.
Sheer battering force or biting ridicule are the favourite weapons.
Their ingenuity is directed almost entirely on personal matters rather
than in the exposition of general ideas. More importance is attached
to discovering some weakness of private character in an opponent or
to attaching to his opinions and views some nickname with an
unpopular connotation than in confuting his arguments or in
examining the soundness and sincerity of his patriotism. The power
effectively within the control of an American party organ can be
exercised much more decisively inside the party before candidates
are chosen than afterwards when the champions are selected and
the battle is formally set. This choice of candidates is however itself
painfully restricted by the almost monotonous sameness of character
among the budding Transatlantic statesmen of the time. Pedestrian
eloquence, high animal spirits, physical vigour and an
unimpeachable rectitude in private life are indispensable
requirements for success in public life in America and politicians
happy enough to possess all these characteristics rather resemble
each other on these lines to the exclusion of any marked or unusual
individuality of character or intellect.

In France and Italy, where the signed article, speaking generally,

prevails, the excellence and weight of the written word in the press
has been profoundly modified and greatly extended. This authority,
however, attaches itself by a natural law to the names themselves,
as they become well known, and is apt to carry the fortunate
individuals, who thus establish themselves in popular favour, up to
greater heights than mere anonymous journalism can scale.
Journalism thus becomes only the ladder of ambition, as far as the
successful writer is concerned, and so far from being an end in itself,
as it should be, is generally, no more than the first step on the road
to politics, even more so perhaps in this respect than the profession
of the law. As compared with the English system the power of the
newspaper itself is very considerably curtailed. The advantage of the
temporary possession of a meteor is a doubtful one. He may mingle
insubordination with brilliancy and even where meekness and all the
journalistic virtues are combined in one pen, the ultimate loss of it
will be the more severely felt. The solid qualities on which the
continuous influence of a great newspaper rests are difficult under
these circumstances to build up and it may therefore be taken as an
axiom that the cultivation of brilliancy in journalism is to some extent
converse to the acquisition of permanent power and wealth by the
press.

The favourable side of the continental system is the maintenance

of a very high literary standard and the acceptance in metropolitan
circles of only the finest qualities of artistic criticism on most
subjects. Nowhere in the world is such power wielded by journalists
in the realms of music, literature, art or the drama as in France or
Italy. It is taken seriously by the cultured public which reads it,
because it is good. It has to be good, because it is taken seriously.
The standard set in these matters is quite unapproachable by the
wealthy and enterprising English press and nothing less than a
century’s education of the English people would be required for us to
see how much in this respect our public taste is inappreciative and
our general journalistic performances inadequate.

The German journalistic system is on the face of it not so far

distinct from the general continental practice, except that they make
less use of the signed article and newspaper properties are
correspondingly more valuable. While the artistic and critical sides of
German newspaperdom are distinctly inferior to the standards
common in France and Italy there is one path in which their journals
can claim pre-eminence in that they treat seriously and reverently all
matters of science and learning, quite apart from any commercial
demand in this direction from their readers. But after making this
deserved tribute to German newspapers a foreign critic can best add
to it by paying them the compliment of treating their newspapers as
in a state of transition from Bismarckian serfdom to American
commercialism. They combine some of the worst qualities of both.
Of independent character in the English sense they have none, as
they are too much under the heel of authority. Enterprise in the
American sense is only adopted in unessentials. In the collection of
news they are not more enterprising than the French and their
standard of accuracy in reproducing it is not very high. Their papers
are printed in Gothic type and written in a still more Gothic style.
Neither in politics nor in commerce, nor in finance is their integrity
above suspicion. Their influence with the public is very considerable,
especially in politics, but the source of their power arises from the
general respect felt by every loyal German for the ultimate and all-
high authority which does not scruple or disdain to use a thousand
methods of pressure in order to sway to its will the minds of men.
Even where this authority is not itself ostensibly at work, as it often
is, its powerful and indirect influence over the press is fertile in
suggesting to the popular imagination those courses of conduct
which will be agreeable to the powers that be.[5]
[5] Although this criticism in the text sounds rather harsh,
it by no means equals many things said in the Socialist
papers against the “Steel Press.” German papers have
never recovered from the combination of bullying and
corruption exercised by Bismarck, and still to some extent
continued, and since his time great commercial concerns
like the Stahl-Verband have had an almost equally baneful
influence. I was unfortunately in Berlin at the time of the
“Titanic” disaster, and looking at the records of that
catastrophic incident even in the best papers, I was not
impressed either by their critical power in assessing the
value of news, or by their judgment in commenting on it.
 Taking the press not only as the great news-distributor of the
world, but also as almost the most powerful existing mechanism for
the moulding of opinion, I do not hesitate to declare that for the last
half of the Victorian century the British press held a position
demonstrably superior to the press of any other country. Although in
many respects, and some of them important ones, of which I have
already mentioned a few, we ought freely to acknowledge our
inferiority, in the two most vitally important attributes of journalism I
believe we have long been unrivalled. The first is good professional
judgment in selecting and absolute faithfulness in presenting the
news of our own country and the most important news of the world.
The second is the spirit of independence and contempt for
corruption, either through the channels of power or by the pulling of
financial strings, which makes it inconceivable for even the smallest
newspaper here to boast of its honesty, an experience, which is a
common enough occurrence, when one travels in any other country.
Whenever corruption or blackmail occasionally finds an unsafe
footing in one of the side-walks of journalism it is looked upon as a
crime, both morally and professionally, which every one must stamp
out, wherever found. Any manager or journalist of experience will
tell you that the suggestion of bribery either at headquarters or with
one of the ordinary daily staff of a newspaper is an experiment of
the utmost danger to any one attempting it. It would most probably
be followed by the instant occurrence of the disaster, which there
was an endeavour to avert; in fact the only chance of escape for the
offender would be the extreme insignificance of his affairs.

But while in many respects much of this stubborn virtue is still a

characteristic of the British press, especially in the professional
sense, yet it is questionable whether, looking at the independence of
our press in the broadest sense, we are not in the course of a
transition to a less desirable state of affairs. It is a matter on which I
should be very reluctant to pronounce a responsible opinion. All I
can see clearly is that a very important change is in progress, the
final result of which it is still too early to forecast. The critical date of
the change was almost exactly at the end of the last century with
the outbreak of the Boer war and the tariff controversy, which
followed. Those two events, while they left the country press in very
much the same position as before, profoundly modified the position
of the richer and more influential daily papers in London. The bitter
controversies, which commenced with those issues, have practically
thrown the great majority of the well-to-do classes in the kingdom
on to one side in politics. Nearly all the richer newspapers, including
one or two influential provincial dailies, naturally followed this lead
and we have the remarkable spectacle of practically the whole of the
important daily press in the metropolis being influenced by the
aspirations, prejudices and casual opinions of only one of the great
political parties. Now without suggesting the slightest imputation on
the professional honour of these great journals nor impeaching their
straightforward honesty, it is clear to me that the relative value of
truth in all controversial matter has been dangerously disturbed. The
mirror of the London press reflects only the drab colours of any
presentation of one aspect of society, reserving all the hues of
sunset for any little feature of the other. The resulting picture is
produced unconsciously and in good faith, but it is none the less
subject to dangerous distortion of the truth. This prevailing
misfortune is growing worse daily and already we have lost the
chastening memory of days, when impartiality was more strictly
maintained in our press as a whole by the adequate representation
of both sides. Society with a big S, has gone entirely on to one side
and has imposed on its press that most hopeless form of
provincialism, which already prevails in high circles in Berlin, of
merely refusing to recognize as possible the existence of culture,
good faith and even of common honesty in those who do not adopt
the opinions prevailing in its own ranks. From this blindness I see no
ordinary means of deliverance.

These somewhat gloomy reflections are applicable only to the

penny press. In the more popular forms of journalism honours
between the two political parties are nearly equally divided. But
stress is to be laid in this matter chiefly on the penny press, because
it is only in these journals or more expensive ones that any
considerable space can be given to political debates and intellectual
and artistic interests. They are a necessity to any man of culture and
it is a disaster for him if opinions on important matters in the leading
organs become stereotyped in what some may regard as a
prejudiced point of view. Again the importance of the penny press in
this connection arises in another form, because in what I am
disposed to consider the Augustan age of the press, the last fifty
years of Queen Victoria’s reign, it was this section which really raised
British journalism to a height of dignity and power, which has never
been equalled and most probably never will be again.

During this golden period, in the course of which the penalyzing

taxes on advertisements and paper were removed, the rise of those
powerful and rich organizations took place such as we pre-eminently
connect with our idea of an “organ of the press.” This idea itself is
probably more completely embodied than anywhere else in the
London Times, which although not itself a penny paper, set the
standard to which the penny morning journals of the United
Kingdom more or less approximated. The foundation of the power
and influence of our great metropolitan and provincial dailies was
continuity of proprietorship and of general policy over a long period
and the possession of great wealth. They were too valuable, both as
properties and as political weapons, to pass easily from hand to
hand and the families in whose possession they remained
constituted a little aristocracy of high ideals and great stability of
character. This represents one side of the medal. The other must be
looked for in the staffs of journalists, who worked for them and the
system of co-operation and the sacrifice of interests on both sides.

Looked at philosophically the keystone in the dignified arch of the

old-fashioned press of the United Kingdom was mutual sacrifice
between the proprietors and journalists. Wealthy corporations
though they generally were, the great English dailies have always
been liable to storms and disasters and progress could only be
purchased by great risks of capital. The proprietors of those days
stood by their papers,[6] as they would not have done by an ordinary
business, staking their private fortunes and exposing their family
comfort to the risks of an unstable source of income. Some
foundered while others rose to great wealth. The proprietors also
stood by their men, whether editors or journalists, and treated them
as members of a family, protecting them, encouraging them and
keeping many a lame dog in employment because he had once done
good work.
[6] For fear that any one should imagine that I am
labouring this point or exaggerating an exceptional
condition of things I think I am free to state here what
would otherwise never be known. The fact is entirely to the
honour of the proprietor and not at all to the discredit of
the paper concerned. To my certain knowledge the late Mr.
John Edward Taylor refused to consider an offer of a million
sterling for the Manchester Guardian, at a time when such
a sum would have very favourably represented the value of
the paper. He wrote to me briefly, asking me not to send on
to him communications of that kind again. I have known
four or five other proprietors of great papers, who would
have been capable of doing the same thing.

As an instance of the generous and courteous

consideration shown by a famous proprietor to a deserving
servant I refer the reader to a letter written by Mr. John
Walter of the Times, dated Oct. 30, 1854, to his
correspondent, Mr. William Howard Russell, as he then was,
acting for his paper in the Crimea. The letter is given in full
in Mr. J. B. Atkins’ “Life of Russell,” and contains very much
more than an acknowledgment of an obligation or the
conferring of a favour.

The sacrifices they required and generally received in return were

devotion to duty, anonymity and frequent concessions in matters of
opinion to the policy of the paper. As the two latter points are vexed
questions of high domestic interest to newspaper men a digression
to discuss them will be pardonable particularly since they have a
very material bearing on the power and influence of any organ of
the press. With regard to devotion to duty a very special quality in
this respect is demanded of newspaper men. Private interests, life
and limb and even reputation have to be risked by them more
frequently than in the ordinary walks of life.

Anonymity is the institution on which the peculiar success of

British journalism is founded. It is a point on which the individual
surrenders with the greatest reluctance. There is something dazzling
in the public reward of successful persuasion and the avowed
capture of other men’s minds. In fact very brilliant writers will never
consent to it, feeling, that their power is inherent in themselves for
which there can be no adequate compensation. So long as either
pure literary quality is aimed at or personal influence desired, such
an attitude is entirely justified. But such men are not permanently
destined for journalism. They must fight out their fate on a wider
field and bear the frost of criticism and the starvation of neglect by
their own strength without the support or constraint of a newspaper
behind them. For journalism proper anonymity has many good
points about it, which escape the eye of the young and
inexperienced. For one thing it builds up the wealth and importance
of the organization, which draws the revenues and distributes the
salaries. Thus it comes about that a young man, who would not earn
a pound a week in any walk of pure literature, where he expects to
be paid also by recognition, can earn a comfortable living by
suppressing his natural desire for fame and doing the necessary
work of the press. But there is a further advantage for the journalist
in anonymity; it is a very effective shelter under which he can do his
daily round of ordinary work without the natural slackening and the
painful fits and starts which pursue inevitably the responsible writer,
who has to put his own name to everything he produces. It may be
possible for the Latin mind to dwell perpetually in the higher levels
of brilliancy but the heavier Anglo-Saxon finds a sheltered routine
more profitable to his genius.
 The advantage to the newspaper of anonymity is more obvious.
The grand manner can be more easily sustained where irrelevant
individual characteristics are suppressed and continuity can be better
preserved in spite of necessary changes of the staff. Again any writer
can almost double his output under the shelter of the paper’s
responsibility and what is lost in brilliancy is gained in steadiness.
Perhaps the greatest advantage is gained by the paper through the
establishment of journalism on a professional basis. The writer of
signed articles is really a pamphleteer, who uses the newspaper as a
vehicle just as in other days he would use a publisher. The journalist
proper, who takes material as it comes along, has to acquire a
certain toughness of taste and suppression of inclination, which in
the ordinary course of things is probably the greater part of the
sacrifice he makes to his calling. It is only a rare writer here and
there, with something of the touch of the missioner or fanatic, who
can successfully fulfil his career as a journalist without acquiring
these callosities and partial mutilations.

The harder sacrifice sometimes required from a journalist in the

occasional subjection of his private opinions was fortunately not
often demanded under the old system. How far any concessions in
opinion to the exigencies of his profession is possible for any
journalist is a matter for a man’s own conscience. But custom has
always ruled these matters in this country in the spirit of judicious
and practical compromise. A wise editor will never be exacting in this
respect because in one eventuality he will get bad work, in the other
he will either break or lose his instrument. It is usually found that an
intelligent sympathy with the general policy of the paper is enough
for most conscientious people. There is no humiliation in conceding
matters of detail and even here there are compensations, for a
subordinate may now and then steal a march on his superiors by
committing his journal in the sense of his own opinions on some
happy occasion. It is essential that these happy occasions should not
occur too often or there may be a sudden parting of the ways
opening up to the adventurous writer.
 Under the newer newspaper régime, where commercial
considerations rule far more than they did under the old family
system, this question of a conflict between conscience and economic
pressure frequently comes up in a most cruel fashion. When a
newspaper passed into the hands of a new proprietor, whose only
object in acquiring it was to have the opportunity of changing its
politics, all the special writers, whose province covered politics,
might be condemned by their sense of honour to go out into the
street. This has happened before now, as every newspaper man
knows. Lord Morley at a dinner given to Sir Edward Cook dwelt on
this precarious feature of the journalist’s life and stated that he
himself during a long connection with this calling as writer and editor
had never yet seriously advised a young man to adopt it as a career.

There is no doubt that the successful commercialization of

journalism during the opening years of the twentieth century has
greatly increased the chances of this painful misfortune occurring to
a writer in the zenith of his career. There is little distinction now
made between newspaper properties and any other, except that
their political influence adds some considerable extra value to their
market-price. In almost the majority of cases they are owned by
limited companies. Their possession does not carry with it the feeling
of a public trust; to own one means just so much money and so
much power. It is safe to say that, while these pages are being
written, not less than four of the London dailies are to be had for an
offer, one of which at least is an exceedingly good property in the
full course of prosperity. The effect on the life of the journalist and
on the type of man, who is now coming into the profession, shows a
change for the worse as compared with twenty years ago. The
hazardous career now offered attracts a different class of men, more
exacting in the way of remuneration, more brilliant and less patient,
with none of the specialized devotion to his own institution, which
was the peculiar characteristic of the Victorian political writer. At
present the newer papers, such as the halfpenny dailies, are living
mostly on the supplies of talent left over from the Victorian era with
a few newcomers of a more sensational type. But some of these will
soon pass away and some will become editors and we shall become
altogether dependent on journalists of another kind, one quarter
special pleader for any cause and three-quarters descriptive reporter.
Education will become a disadvantage and motherwit with a turn for
word-spinning will take its place.

To return to the main question of the actual power over opinion

exercised by the press I am inclined to think it was at its maximum
in this country during the Victorian age. Not only one but three or
four prominent journals would guide opinion during a decade, of
which the Times stood easily first. Statesmen would take hints from
newspapers or privately from journalists. The leading articles every
day would be scanned by politicians looking for approval with an
eagerness, which is already becoming a thing of the past. Of
instances frequent enough and already well-known to the public, it
will be sufficient to select only one, the celebrated advice given to
Lord Beaconsfield by the late Frederick Greenwood, and acted on by
the former with prompt adroitness, to buy the Suez Canal shares for
the British Government, advice which ultimately led to our control of
Egypt.

The influence of a newspaper on the opinions of its readers is

largely a matter of reliance and discretion on the part of those who
guide its policy. Of course there is the avowed political partisanship,
officially acknowledged and attracting the support of most of its
readers for this cause alone. In this respect, however, no paper can
claim to influence its readers, because they have formed their own
opinions for themselves on the main issues already. The real power
of a paper depends chiefly on the skill with which it is kept in the
background and the severe economy of its use. Any blatant
partisanship on unnecessary occasions begets in the reader the habit
of discounting its repetition and of steeling his will in resistance. This
is sometimes so strong an automatic habit that many men make a
point of reading something of an opposition journal, so as to stiffen
their prejudices and give an indignant edge to their own version of
patriotism. It is getting truer every day that the lecturing leading
article is little appreciated and influence is more effectually exerted
by the presentation of news.

This is conspicuously true of the more popular halfpenny journals.

These are not all of the same class, as those which once occupied
the position of penny morning papers retain many of their old
following and are thus encouraged to continue something of the
style and of the make-up, which was suited to their narrower
circulation. Of the new and frankly commercial press one may say
with some confidence, that they have no influence in the old-
fashioned sense at all. In all matters of opinion what they say is a
matter of indifference. Their function is to supply to those, who
already agree with them, a brief and effective setting for obvious
facts and sometimes just so much misrepresentation as to make
unpalatable facts a little more tolerable. In London it is conspicuous
how insignificant their political efforts may be. In the last three
elections the most populous parts of London have on the whole
voted in the sense contrary to the two or three sensational journals
which have the largest circulations in those localities.

With all the merits of these popular journals, and these are very
marked in comparison with the halfpenny press of other countries, it
is impossible to deny that the recent commercialization of journalism
is an irredeemable loss to this country. We have probably in the last
twenty years parted silently with an asset of unique value. It was
perhaps inevitable and no one need blame themselves or any one
else. In fact, the group of successful men, who have rather
brilliantly, in one sense, effected this revolution, are not responsible
for the circumstances, which made their own victory necessary. One
may perhaps grumble at the rather obvious insignificance of the new
“replacers.” No personality seems to emerge from among them and
one is tempted to conclude that the task they have effectively
accomplished was one more suited to Attila than to Napoleon.

The real dominant factors of the modern press and the press of
the future are the machine, the telephone and the special train.
Production by the million is an exacting master. Instead of three
hours for a considered version of facts or opinion, the modern writer
is often given fifteen minutes, in which to turn out a smart
distortion. The more a man can resemble a Linotype machine the
more useful will he be to the paper of to-morrow. He must of course
be complicated in organization, his mechanism must be ingenious
enough to conceal his mental subordination. But just as the pressing
of any key on the composing board brings down always the same
letter so will it be required from the brilliant, up-to-date journalist of
the millennium, that he must react automatically with the most
faithful resemblance to the accuracy of a machine to each stimulus
afforded by varying events, popular emotions and the ideas of the
market-place.
 CHAPTER V

THE NEWSPAPER AS A BUSINESS

ORGANIZATION

The future will belong more and more exclusively to organization and
machinery; and this obiter dictum may be held to be as true of
newspapers, as of anything else. It is necessary in the first place to
make a clear distinction between these two terms, as they each
describe a method of effort, which runs very easily into the other,
without any obvious dividing line. Roughly speaking, the term,
organization, is generally applied to a systematic use of human
endeavour; while the term, machinery, denotes that part of our
activities which we have succeeded in delegating to steel and iron
and thereby in saving the wear of flesh and blood. Obviously the two
terms to some extent overlap on the same ground, because system
requires the use of machinery, and machinery must be employed in
systematic fashion.

From the point of view of organization the chief requirement of a

newspaper is continuity; and this continuity must be maintained in
two ways. A newspaper in order to be successful must maintain the
same kind of continuity of opinion that a politician has to establish
for himself in order to secure the permanent support of his
constituents. Side by side with the other and equally necessary for
success is the same continuity of good management and energetic
business development, such as is aimed at in the course of any
prosperous business. This double life of newspapers thus
distinguishes them very markedly from any ordinary enterprise and
leads to certain very distinct and not generally observed results.
 Should a newspaper be conducted with conspicuous success for a
long period by its editor and staff and also enjoy the benefit of wise
and far-seeing management, the work of each redoubles the value
of the other to an astonishing extent. The result will be the
establishment of a property of enduring value, not to be paralleled in
any other business, not even by the history of any powerful banking
concern. On the other hand a permanent failure in either respect will
sooner or later bring about the ruin and decease of the oldest
established journals. The process of such a failure will, however, be
different from the course of natural decline to be observed in
ordinary commercial life. Successful editorial conduct of a newspaper
will often prolong its career in spite of mistakes of management,
while good business ability will keep alive for some time a journal,
whose readers are dropping off day by day. It seems to be a law of
newspaper life that mistakes in this business have far-reaching and
not easily discoverable consequences; the fatal decision and critical
mistake will not receive its inevitable recompense until after a period
of delay, which makes the original cause of the disaster only a
matter of conjecture. There is nothing more mysterious, even to a
highly-skilled and discerning eye, than the decline and fall of many
powerful and long-established newspaper properties.

The commodity, which a newspaper has to dispose of, is the most

valuable in the world; publicity. This commodity it dispenses freely
for no consideration whatever in its news columns. It has the power
to set generals, politicians and artists on pinnacles of success and
glory by keeping them before the public and under other
circumstances it can ruin and drive to despair the courtier, the public
servant or even the humblest individual. Any one who has taken a
practical part in our mysterious calling will appreciate its terrible
power, especially in the latter sense. We have all been witnesses of
the despairing appeals “to keep something out of the paper”; as we
are equally aware of prominent men, whose careers, sometimes
contrary to merit, have been created for them by the newspapers. It
is out of the same commodity, supplied under different conditions for
purposes of business, that the newspaper acquires the magnificent
revenues from which it can defray the enormous expenses required
by a modern fully-equipped organization for the collection and
presentation of news.

Advertising is the newspaper’s backbone. The world is only

beginning to realize how vitally necessary it is to business. Probably
from £40,000,000 to £50,000,000 a year is spent on advertising with
various journals and periodicals in this country alone. Perhaps as
much is spent in Central Europe and at least four times as much in
North America. All these vast revenues are a subsidy paid by the
public in aid of journalism and for the provision of news. They
enable the newspaper proprietor to give to his readers a product,
which costs him from four to ten times the amount, which he
receives from them in purchase of his papers and in return they give
to him and his advertisers part of their daily attention and ultimately
they requite him by buying more or less of the articles advertised in
the paper. Thus there is an ingenious exchange of services, which
makes the management of a newspaper in a commercial sense
almost as complicated a process as its editorial conduct.

The process is attended by a subtle danger. With the increasing

expenses of modern newspapers under the stress of competition the
necessity of swelling the advertising revenue of a paper becomes of
paramount importance. So the courting of prominent advertisers is
every day more and more the preoccupation of a newspaper
manager and he is apt to listen too favourably to any
representations made by strong monied interests and himself to
exercise a corresponding pressure on the editorial side of the
enterprise. Here is the point, where the newspaper, as an essential
feature of its career as a business, may be said to have a conscience
or should have one. The tendency to a decline and fall into the last
stages of commercialism must at all costs be resisted. If not
resisted, it may become suicidal and by ultimately weakening and
losing the hold which a newspaper has on its readers, it may
sacrifice its capacity for usefulness to the public and lose its own
source of strength and revenue. Or worse still, the tendency may be
followed downhill almost to a criminal extent and lead to organized
fraud and systematic blackmail.

Although there are in the United Kingdom considerable differences

both as to accepted principles and also practice between one journal
and another in this respect, yet we are fortunately, with rare and
insignificant exceptions, free from the criminal methods of
prosecuting success. The press of other countries in this aspect we
need not consider. With us the problem of relative independence
with regard to advertisers presents itself within a comparatively
small compass. It is a question of how far newspapers and other
periodicals allow the use of their news columns to the puff
preparatory or supplementary for the benefit of those firms and
businesses who contribute freely to the revenues of the advertising
columns. This practice is on the whole fairly common. There is in it
nothing in any way immoral or disgraceful and it really resolves itself
into a question only of dignity and expediency. Perhaps one might be
within the mark in attributing such practices to a greater or less
extent to the weaker half of the press of the United Kingdom. Those
who avowedly adopt these methods place themselves on an inferior
plane and to a certain extent lower their reputation and weaken
their bargaining power. Still it must be admitted that such
surreptitious puffing is often adopted under pressure even by
wealthy and powerful journals to an extent, which makes resistance
on principle to the same demands exceedingly difficult for their
weaker competitors. Among other disadvantages these puffs
ultimately tend to lower the value of the columns openly sold to
advertisers and thus to impair these as a source of revenue.

As I have said elsewhere,[7] the philosophy of publicity is rather

hard to grasp. In some forms it comes perilously near to charlatanry
and quackery and yet in the modern world it is not only a valuable
aid to business but absolutely indispensable. Although the practice
has been known to all ages, it is only the development of the
immensely productive power of the factory system, which has
caused its enormous extension during the last century. In former
times goods were produced with difficulty and found their hungry
markets waiting for them. It is entirely different now-a-days. The
chief modern problem is to sell goods fast enough to prevent a glut
of production. To take a concrete instance from modern America, the
output of motor cars as these lines are written is considerably more
than one a minute and in order to secure continuous cheapness of
production this rate of output must be maintained and probably even
increased. All this flood of production has to be marketed without
delay and without intermission. The missing of even one month’s
sale of such a prodigious output would entail the bankruptcy of half
the manufacturers in the kingdom.
[7] See “The Laws of Supply and Demand,” Cap. XV.

It is advertising which supplies the remedy for their ever-present

difficulty. It affords the chief practical solution of the paradox of
modern industry, which requires that goods shall be manufactured in
immense quantities in order to secure cheapness of production and
yet will not allow that they should be put on the market in too large
quantities at a time for fear of creating a glut and lowering prices.
Demand must never be satiated. It must be perpetually stimulated
so as to maintain a steady suction at least equivalent to and
preferably exceeding, the normal rate of output. The most effective
and almost universal method of obtaining this stimulation of demand
is by advertising.

Advertising began by aiming at mere publicity. Then it became

combative and assertive of individual superiority over rivals. As this
grew stale, it assumed blandishing and seductive methods, flattering
the customer and appealing to his intelligence, his discrimination and
his good taste. The latest tendency especially in the technical
journals, where immense sums are spent in this business, is to
become soberly educative. The customer is offered gratuitously the
benefit of the immense experience acquired by the advertiser from
an extended business in meeting the particular needs of the buyer.
This is an eminently legitimate and highly successful method. It is
perfectly true that, where a speciality is concerned, the seller may
have far more detailed experience than the buyer himself. But it
hardly meets the more general case, where the nature of the want is
trivial and it is only a question of which satisfaction to take out of a
choice of several.

One of the difficulties about advertising, of which the newspaper

manager has to take account, is the element of misrepresentation,
which is apt to creep into it. The stereotyped precaution, which has
always been taken to prevent misrepresentation being such as to
involve the newspaper proprietor in damages or to embroil him with
other customers is to refuse to insert any reflection or
disparagement of any recognizable rival goods. The advertisement is
therefore driven back on to a rather tame proclamation of general
excellence and of the pre-eminence of the article advertised over
rivals in general. Of course the utility of any device, so tame as this,
is rapidly exhausted, so that advertisers have long learnt to vary the
appeal and the claim in every possible way. But although the form
changes, the methods are few. The earliest method was the attempt
to use literary skill, but as this necessarily appealed only to a class of
people very much on their guard against advertising of all kinds, it
was soon abandoned. Another method was the surprise. A long story
would be printed with a little tag at the end advertising some
nostrum or necessary. This was speedily discounted and disused.
Then mere blatancy became the general rule. Advertisers appealed
only to the eye by wearisome iteration. Curiously enough such a
policy, apparently trivial to a primitive degree, has held its own for
decades against devices of a much more elaborate kind. But in the
newspaper itself severe limitations are imposed on this method both
by the paucity of type faces and the mere cost of space. It has come
therefore to be almost exclusively the weapon of the very rich, who
are able to buy whole pages at a time of the most widely circulated
and most expensive journals. Lastly and perhaps the most
successfully of all, illustration has come prominently into use. Here
again the limitations of the medium impose themselves. It is not
every kind of design or sketch, which is effective under the rough
conditions imposed by the rapid printing of the daily press. The
managers of newspapers themselves being aware of this are not
anxious to encourage this form of enterprise and some of them
exclude it from their columns. The legitimate field for its full
florescence has now become the pages of the popular magazine,
which are printed with monthly deliberation on the flat and thus
secure a high degree of excellence in technical execution and
reproduction. The American magazines are the most suitable home
for brilliant expository work of this kind and in many cases the
ingenious advertisers have succeeded in making their advertisement
pages a serious rival in interest with the pages in the text.

All these efforts, while they are strictly speaking the chief concern
of the advertiser, become by proxy the daily problem of the
newspaper manager and of his familiar spirits, the advertisement
solicitors for the journal or periodical. This is a task very much better
understood and executed in America than in Europe and a high
degree of expertism in advertising has become a sine qua non of
newspaper management everywhere. The work is as often as not
now carried on by a highly-trained staff including writers, artists and
canvassers, so that the manager himself has nothing more than a
general supervision and direction of policy. It is especially his
province rightly to appraise the class of readers, whose patronage he
has, so to speak, to sell to advertisers, to advise as to the best
methods of approaching them and to lay down general rules and a
scale of prices regulating the advertising, which his paper is
prepared to take. Such a responsibility is a very serious one because
the rules and conditions, under which this traffic has to be carried
on, cannot be changed very often and once established the rules
must be observed with judicious strictness, as any suspicion of
partial or favoured treatment would unite his customers fatally
against his paper. He must never forget that the bulk of his custom
comes to him through a profession of the most suspicious people in
the world, the advertising agents, whose pre-occupation it is to
secure most-favoured-nation treatment each for his own customers
and to prevent any one else stealing a march on them.
 Let us examine this problem as it presents itself to the manager of
a London daily morning newspaper. The complication of it can be
seen by carefully examining the columns of a typical daily like the
Morning Post or Daily Telegraph. Advertisements for these papers
divide themselves into two classes, displayed and classified. In the
first class come all those miscellaneous announcements, whose
character we have discussed in general terms above. The advertiser
in these cases practically buys so much space, sometimes in column
form, sometimes across column rules, in which case he is almost
invariably charged a higher rate. In this space he frames his
advertisement using the special kind of type laid down by the rules
of each paper, which in the United Kingdom vary greatly from the
extreme conservatism of the Morning Post to the unlimited license of
some of the smaller provincial dailies. It is becoming increasingly the
practice to sell space of this kind at a “flat rate,” which is an
American term meaning a fixed price per inch with reductions for a
quantity, allowing the advertiser to make his advertisements what
size he likes and to repeat them at his own convenience, as opposed
to the older English custom, where so many specific columns and
half-columns were sold at certain regular intervals of recurrence,
restrictions which imposed needless trouble on the advertiser and
often interfered with the most effective display of his
advertisements.

But with regard to classified advertisements, that is,

advertisements grouped under regular headings, more old-fashioned
usages prevail. Probably no two papers in the country have exactly
the same scales for this kind of advertising. The reason is not far to
seek. Every paper has some little connection in a special class of
advertising arising out of the ineradicable habits of the public. For
instance the Morning Post is pre-eminent for domestic servants, the
Daily News for pressmen and compositors and I remember one
provincial daily, now dead, which even in articulo mortis was the
only organ through which the barbers and hairdressers of Lancashire
sought for new situations. It followed that the scales charged for this
extremely varied volume of custom are roughly governed by the
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