Review of "Mental State: Navigating Australia’s Insane Mental Health System" - by Dr. Mark Cross

Mark Cross, a psychiatrist with lived experience, tells a repeating story of “people in distress, experiencing a crescendo of panic, presenting to emergency departments only to be left waiting in the emergency section for many hours, often days, due to a shortage of available beds in the mental health unit.” Even when beds become available, Mark describes the frustration of offering crisis support without the follow-up needed for true recovery.

This is a story that echoes throughout Australia’s underfunded, fragmented public mental health system and the inadequately resourced community mental health system that could be and should be better supporting the individuals who should need crisis care.

Mark has spent decades confronting the challeneges of Australia’s "mental health system" and his own lived experience drives the urgency of Mental State. His book is part manifesto, part plea, and deeply personal in its critique of the system he knows all too well.

In the Forward, by Janet Meagher AM, one of Australia’s foremost lived experience activists, it says “the title of the book is confronting, accusatory and unashamedly blunt. The book itself is starkly honest, coming from the heart with a strong empathy, and at times is difficult to read.”

Mental State is both a critique and a guide, it is clear and engaging, blending humour, compassion, and frustration as it navigates the complexities of mental health care in Australia. Mark offers a detailed account of the system’s failures, particularly the gaps between policy and practice, while emphasizing the need for both better resourcing of the public mental health system and a more compassionate, community-based approach to care.

Several times the book touches on the deeper question of “how we think about mental ill-health” and where we may need to focus our efforts rather than just continually repairing a system whose underlying assumptions are faulty. As Mark says we must “take a long, close look at opportunities to prevent mental ill-health by addressing societal causes such as stigma, poverty, homelessness, trauma and racism,” and also  “… many potent causes of mental health issues are in fact societal and familial in nature; our backgrounds, our upbringing and the ongoing stigma we face in our lives plays a huge part in our wellbeing”

The book provides information and insights into the details of what happens to a person in a mental health crisis, the harsh realities of the Emergency Department, the power struggles and negotiations around limited beds, and what happens in the inpatient units. This is excellent, albeit confronting, inside information for health care workers who work on the periphery of the system. As Mark says “Healthcare models continue to be shaped and often constrained by the moral and legal frameworks of the society in which they operate, sometimes to the detriment of those needing care and in some cases in contravention of human rights”

In the Chapter on “How we Used to Treat it” Mark explores the historical evolution of treatments for what has been regarded as mental illness. He traces mental health care from ancient civilizations like Egypt and Greece, which used holistic approaches such as rest, diversional therapies, and early forms of talk therapy, to more brutal treatments in later periods where cruel practices, and violent interventions were used. Dr. Cross critiques how the language and power dynamics in psychiatry have historically caused harm. He emphasizes the need for more compassionate, accessible, and culturally sensitive approaches in modern mental health care, acknowledging the deep-seated issues in past treatment models.

Mark situates the current challenges of Australia’s mental health system within this broader historical context. A key theme in the book is how past reforms or promises of reform have failed to bring about lasting change. The book emphasizes that, while the deinstitutionalization movement of the late 20th century aimed to create a more humane approach to mental health care, it also left many without adequate community support.

The lived experience perspective given in the extract from Sandy Jeffs (see “Out of the Mad House by Jeffs and Leggatt – two remarkable lived experience advocates) is essential reading for people seeking to get a fuller understanding beyond simple good and evil historical narratives. Mark provocatively asks regarding the period prior to deinstitutionalisation, “could the system have improved to the point of becoming a truly dynamic, peer led system, with close ties to community teams and networks? We will never know, because by this point there was general consensus in the Western world that the old mental hospitals should be closed.”

Mark’s discussion of historical context is both insightful and critical, providing a window into the systemic roots of today’s challenges. No person can encompass the whole picture and Dr Cross’s experiences have mainly been in the public mental health sector. If I had one critique, it is while Mark acknowledges the importance of community based mental health services, there is a need for a more comprehensive insider account of the community mental health sector. This is particularly relevant as there are hundreds if not thousands of community-based organisations, a number of whom have been in operation for over one hundred years. Many were started by groups of people with lived experience of mental ill health and have employed tens of thousands of people increasingly people with lived experience. The community mental health sector however has experienced more funding ups and downs that a “fun park” roller coaster. Most recently this is manifest in the now clearly documented significant unmet need for essential psychosocial support.

Mark recognizes the importance of the not-for-profit Community Managed Organisations (CMOs) in providing psychosocial support to individuals with complex needs, but the book falls short in fully capturing the impact of chronic underfunding and the endless chopping and changing that has plagued these services. A recent example was when programs like Personal Helpers and Mentors (PHaMs) and Partners in Recovery (PiR), which offered vital support, were defunded around 2018. After much difficultly many people eventually transitioned to the NDIS, while many others were left without the help they needed. The recently released DoHA Unmet Need for Psychosocial Support Report underscores this issue, noting that “more than 238,000 people with severe mental illness in Australia are going without the psychosocial support services that they need.” 

Mark’s notes, and his analysis resonates, with findings from the Productivity Commission’s 2020 Report on Mental Health Services in Australia, which called for “Australia’s mental health system to be holistic and person-centered...particularly for those for whom clinical treatment is not the complete solution… We must expand community-based services to bridge the gap between clinical care and everyday community needs.” 

One of the most detailed and informative parts of the book is the Chapter “When You’re In the Middle it gets Serious”. Here Mark’s detailed insider’s knowledge is high quality and gold to those seeking to know how some details of the process within the public mental health hospital system works. He says, “it should not all be about beds, but they are the currency of our emergency departments”. There is no substitute for reading this section carefully and I recommend the reader to do so. Needless to say it is not a pretty picture. It here also that Mark discusses the rise of and the value of alternatives to hospital ED. There are some great initiatives here some old and some new.

Mark’s insights into the public mental health system are shaped by years of practice in hospitals and clinics. He describes the strain of working in an environment with a severe shortage of beds, where patients in acute distress often face long waits for care. As he puts it, “The wait for a bed was like waiting for rain in a drought: desperately needed, but all too rare.” His critique mirrors the Productivity Commission’s call to address the “cycling of people in and out of hospital at great personal cost.” Mark also highlights the emotional toll on staff, who are often forced for a variety of reasons (under staffing, and resourcing, overwhelming numbers of presentations, inadequate safe rooms, lack of mental health clinical staff in EDs, focus on physical health crisis, etc.) to use confinement and restraint in situations of crisis, chipping away at their own sense of humanity and causing moral injury.

He discusses the ethical dilemmas and emotional toll associated with these practices, both on patients and on the staff required to carry them out. Mark’s narrative captures the humanity and complexity of these situations, describing the impact of such measures on people in crisis: “We have no choice but to restrain them, but each time we do, a little piece of our humanity gets chipped away. It’s not why we became doctors.”

The stresses on hospital staff are another focus of Mark’s critique. He emphasizes how underfunding, and resource constraints contribute to high levels of burnout among healthcare workers, leading to a loss of skilled professionals from the field. This stress is compounded by the system’s inability to provide holistic, trauma-informed care, which leaves both staff and patients in a state of constant crisis management. Again, as many other reviews and reports have found, such as the National Mental Health and Suicide Prevention Agreement, there is a great need for a “sustainable and resilient workforce, particularly in rural, regional and remote communities”, a goal that remains far from reality.

Mark acknowledges the compassion and expertise of many of his colleagues, even as they navigate a system that often works against them. Yet, he is adamant that the current model—reliant on acute interventions and emergency responses—cannot address the deeper needs of people living with severe mental illness.

Mark’s reflections on the state of public mental health services and his call for a system that prioritises prevention and recovery and balances acute care with community supports aligns with key recommendations from many policy and advocacy bodies. Mental Health Australia, Community Mental Health Australia, Mental Illness Fellowship of Australia, SANE Australia, Suicide Prevention Australia, Lived Experience Australia and Australians for Mental Health to name a few.

A strength of Mental State lies in Mark’s use of personal stories to humanize his critique. By sharing his struggles with anxiety, he breaks down the “us and them” divide between professionals and patients. He writes, “I know what it’s like to be on the other side of the desk, to feel like a diagnosis rather than a person.” These narratives connect deeply with the sector’s emphasis on including the voices of people with lived experience in shaping services. The Productivity Commission’s call for a “mental health system that listens to and incorporates the insights of those with lived experience” finds a real-world example in Mark’s approach.

Mark’s critique of Australia’s mental health system centers on its crisis-driven focus, where individuals receive treatment only when they reach breaking points. He emphasizes the need for a holistic approach that addresses social determinants like housing and employment alongside clinical care. This aligns with the National Mental Health and Suicide Prevention Agreement’s call for “reducing system fragmentation and increasing the focus on prevention and early intervention…. We cannot continue to rely on a model that treats people only when they reach breaking point.”

In the central parts of the book Mark provides a description of many components of the broad domain of mental health and ill-health from the validity and reliability of psychiatric diagnosis and prognosis; the limitations of “the medical model”; the views of other cultures; the social determinants; the holistic approach; issues of safety; controversies around medication; peer support; psychosocial supports; the rehabilitation mode; the recovery model; Helplines and Telehealth; Primary Health Networks; Medicare Mental Health Centres; the role of GPs (“over 80% of all psychiatric medications are prescribed by GPs”); Psychologists, Specialist Psychiatrists; Local Health Networks and Private-sector health providers. In regard to the latter Mark makes another provocative statement “If I or a family member were to need admission to a mental health facility … Applying the Mark Cross litmus test, I’d go private all the way, saddened and guilty as that makes me feel”.

The book is a good compendium of the components of Australia’s mental health system, though as always things are complex, there are a few key missing pieces and as always there are a wide variety of views on the details, pros and cons in each of the components discussed above.

The chapter “When the Law Steps in” is essential reading for people seeking to understand how the current system is underwritten by legislation. While each State and Territory’s Mental Health Acts reflects unique local priorities, they share common principles around seeking to balance involuntary treatment, patient rights, and mental health services.

In the latter half of the book, the often-overlooked issue of mental health struggles among healthcare professionals is highlighted. The book delves into the high rates of burnout, depression, and suicide among doctors, nurses, and other frontline healthcare professionals. The pressures and challenges that contribute to these issues, including long hours, the emotional toll of caring for ill patients, and the stigma within the medical community around seeking help are discussed. Mark calls for systemic change to provide mental health support for people working in the healthcare system, who are frequently under immense stress but may feel unable to seek care themselves.

Towards the end of the book, Mark explores the importance of early intervention and prevention in mental health. He advocates for a proactive approach to mental health care, emphasizing that addressing mental health issues early can prevent more serious problems from developing. This includes the need for community based psychosocial support, public education, and the need for systemic changes that prioritize compassionate, and person-centered care and treatment over bureaucratic inefficiency.

In Mental State, Mark Cross offers a deeply personal critique of Australia’s mental health system, emphasizing the need for a more integrated, compassionate approach. His insights resonate with broader calls for reform, such as the need for more psychosocial supports and community-based services. As he writes, “Every person who falls through the cracks of this system is a reminder that we must do better—not just in policy, but in practice.” Rachael Green, CEO SANE Australia in a key Insert echoes this sentiment, highlighting Mark’s “commitment to seeing the person beyond the diagnosis… In Australia, the impact of mental health issues accounts for 13 per cent of the total disease burden but receives only 7 per cent of the total healthcare funding. This is serious underfunding. It’s also shameful structural stigma.”

The book’s message is clear: while challenges in mental health care are substantial, they are not insurmountable. With a focus on community support, prevention, and a willingness to address the social roots of mental distress, a better future is possible. The long-term advocates and champions for change whose shoulders have been pushing up the Sisyphus boulder of reform towards that light at the top of the hill for many years may sigh with exhaustion, but there have been gains that are slightly ahead of the setbacks. As always new energy, and bright eyed and bushy tailed advocates bring their optimism for a better world.  So, Mark’s vision, of hope, grounded in the belief that with the right support, everyone can find a way to a better life, is an inspiration for all and keeps alight that beacon of hope at the top of the hill.

...... Thanks to Julie Millard AM for her assistance with editing this Review.

Jan Owen AM Hon DLitt Patrick McGorry Ian Hickie AO William (Bill) Campos Rachel Green Chris Raine Chris Picton Peter Malinauskas Elizabeth Deveny Ailsa Rayner EBE BPsych Terry Slevin Rob Moodie Robert Stirling Robert Ali AO Robert Donovan Toby Adams Tom Brideson YES Emma McBride Emma Griffiths; Ingrid Hatfield ; Cathy O'Toole ; Tony Stevenson Lisa Brophy, EdD, MSBA, RN, CNE ; Raymonda Dijkwel ; Gerry Naughtin ; Dr Mark Cross