What do you think?
Rate this book
Mental State: The insanity of Australia's mental health system - and how to fix it
A manifesto about what's wrong with Australia's mental health system and a guidebook for how to treat it, by a neurotic shrink who lives it every day.
Psychiatrist Dr Mark Cross has spent most of his adult life working in the mental health system. He also suffers from anxiety, as do three out of four Australians at some point in their lives, so he knows first-hand the challenges, successes and failures facing both patients and professionals. What he has discovered is that while Australia's physical health system is world-renowned, its mental health system falls miserably short. From soaring out-of-pocket costs to excruciatingly long wait times and overworked nurses to inhumane treatment conditions, we are failing people at all stages of their search for clearer, calmer minds. In this manifesto, Dr Cross takes a deep dive into mental ill health -- who suffers, why, how we treat them and what we need to do better. Written in Dr Cross's warm and entertaining style, MENTAL STATE includes his own stories of working inside the system, as well as the experiences of consumers attempting to navigate it and the practitioners working within it.
Psychiatrist Dr Mark Cross has spent most of his adult life working in the mental health system. He also suffers from anxiety, as do three out of four Australians at some point in their lives, so he knows first-hand the challenges, successes and failures facing both patients and professionals. What he has discovered is that while Australia's physical health system is world-renowned, its mental health system falls miserably short. From soaring out-of-pocket costs to excruciatingly long wait times and overworked nurses to inhumane treatment conditions, we are failing people at all stages of their search for clearer, calmer minds. In this manifesto, Dr Cross takes a deep dive into mental ill health -- who suffers, why, how we treat them and what we need to do better. Written in Dr Cross's warm and entertaining style, MENTAL STATE includes his own stories of working inside the system, as well as the experiences of consumers attempting to navigate it and the practitioners working within it.
307 pages, Kindle Edition
Published August 1, 2024
26 people are currently reading
118 people want to read
Ratings & Reviews
Friends & Following
Create a free account to discover what your friends think of this book!
Community Reviews
Displaying 1 - 10 of 10 reviews
August 30, 2024
Warning, this is my longest review, and longer than my review of June Singer’s ‘Boundaries of the Soul – The Practice of Jung’s Psychology’. This is so long I am not expecting anyone to read it through (it will take a long time). As usual my purpose is to understand my own thinking as I consider the perspective of another. I hope the length is a measure of how deeply I have thought and reflected about this book.
This book popped up as a suggested read and ticked a lot of boxes. I am interested in the Mental Health System in Australia, having spent most of my career working in it. I agree that we could do better structurally and individually. I wanted to find out about Dr Cross’s ideas and if they had merit and were useful. Some of this review will appear negative and I want to preface this by saying that I agreed with 95% of what Dr Cross wrote. As I read I had ‘yes, but….” moments often when I disagree with the author or when they write something so well I want to remember it for myself. I have not had this many ‘yes, but…’ moments since reading June Singer.
Like Dr Cross, Australia is the third country I have resided in. I lived in Stoke-Newington and worked in Hackney and we are a similar vintage. In spite of this I am not sure I have ever come across Dr Cross professionally, although colleagues have, and say he is a wonderful Psychiatrist and very funny. We have a number of philosophical differences which will become apparent.
Foremost of these is that I found the underlying philosophy toward society of a Rousseauian Romantic (I acknowledged I am Hobbesian in my outlook). Dr Cross has a number of utopian and idealistic suggestions which assume limitless resources, via public funds. Like any good Rousseauian, Dr Cross never mentions, acknowledges or potentially sees the free rider problem within the provision of mental health services. The free rider problem is an economic concept of a market failure that occurs when people are benefiting from resources, goods, or services that they do not pay for. If there are too many free riders, the resources, goods, or services may be overprovided. He ignores the question of how do you identify freeloaders and then what do you do about them? This is something public mental health services only manage covertly in the shadow of the collective unconscious. In Rousseau’s utopia there are unlimited resources for the noble savage to exploit, in the real world there is not. A question I wrestle with is how much responsibility should a state have towards it’s citizens vs how much an individual should have responsibility towards themselves (and suffer the consequences of poor decisions). If you believe in free will, you believe in allowing people to make bad choices and cope with the consequences of those choices in what might be seen as a Neo-Liberal manner.
Another Rousseauian trait is apologising for the sins of others, before the sins of your self. I am not sure what I make of this. Dr Cross writes that as a profession we need to “own up to the abuses of the past and acknowledge the often traumatising mistakes our predecessors made so we can move forward in a healing way” (p 62). I think Dr Cross (like me) should first own up to his own abuses. I have secluded, restrained, and forcibly given people medications (often in the form of an injection) against their will more times than I care to remember. It was never a good or pleasant experience and always occurred in a context. Nobody left these situations without trauma that was not co-created (I would argue against a victim – perpetrator narrative and believe that our lives are co-created). Dr Cross is happy to throw his professional ancestors under the bus without acknowledging his own engagement with practices which are now considered questionable. The closest I found he went to this is “I have had to apologise to colleagues for leaking stress in unhelpful ways” (p 178). I am always interested in clinicians who can specifically acknowledge where they have got it wrong, and what they have learned from it. I am not sure this book is the appropriate forum to do this, but an acknowledgement of specific professional failings reminds us we are human (as were our ancestors engaging in the best practice they knew at that time). To apologise on their behalf seems facile.
Cross repeatedly sets up a straw man in his return to ‘conversion therapy’ when ever he can. I felt it was implied within the mental health industry as being full of zealots wishing to help people ‘pray the gay away’. I have worked in the industry for nearly 30 years and not ever come across conversion therapy being suggested or advocated for (even by my openly Christian colleagues). Cross’s treatment of Conversion Therapy is the epitome of a ‘Strawman’ argument. It is a dog whistle to the imaginary woke mob to provoke outrage amongst them that this is happening. I found Dr Cross repeatedly made strawmen of our religions generally. “In our places of worship, there could be a dramatic change if mental health issues were openly and factually discussed rather then described as demonic possession or as payback for sinful behaviour. Preaching tolerance, love and acceptance from the pulpit would be valuable” (p 200).
Dr Cross did not acknowledge the role of religion as a positive contributor to peoples mental health and the provision of mental health services. A dirty secret of the mental health industry is that one of the best predictors correlated with mental wellness is engagement in a religious community. People who engage in worship seem to be doing something that is protective of their mental health. Is it the values inherent within a religion? Is it the sense of community, relationships, and sense of belonging that is provided? Is it being able to accept your suffering? One thing the mental health industry does not really cope well with is the concept of the soul (and that is why I love Jung, because he leaves room for it). Blaise Pascal's said “There is a God-shaped vacuum in the heart of every [person] which cannot be filled by any created thing.” and he also said “Men never do evil so completely and cheerfully as when they do it from religious conviction.” Religion taken to far can be damaging and that does not mean a life absent from faith is ideal either. Balance in all things, I take a cosmopolitan view of taking what is helpful and useful. I co-read this with C.S. Lewis’s impactful, The Abolition of Man. Even people with Mentally Illness must be held to a moral standard, and holding people to a standard is not a Rousseauian strength. God has to balance mercy with justice. It is the role of mental health clinicians to be on the side of mercy. We would do well to remember our provision of mercy is balanced by the providers of justice.
Sandy Jeffs writes a number of thoughtful and well written segments of the book showing a nuanced understand of issues surrounding mental illness from a consumers perspective. She acknowledged that the old institutions were not all bad and gave credit to the care she received from the nursing staff. It has made me want to read her books in the future. It contrasted the dichotomous thinking that Dr Croos sometimes expressed.
As a mental health nurse, Dr Cross played to my bias that “there was a clear need to recruit more mental health nurses” (p 22). Sandy Jeffs also bemoans the loss of mental health nursing as an apprenticed speciality. I am an ever shrinking part of my profession. As a metaphor, early in the COVID experience, nurses like me were being offered to do a certificate to work in ICU, so if the worst happened I could be an ICU nurse too. The best argument I gave people to get immunised was that I could be their completely inadequate ICU nurse if they became unwell. I respect the skills of my specialist ICU trained colleague. Unfortunately, Mental Health Nursing is not given or recognised with the same respect. Registered nurses think they can be a mental health nurse and ‘go have a break’, and then cower behind experienced mental health nurses when things become difficult, because ‘it is outside my scope of practice’. No Shit Sherlock, and the mental health nurses are complicit in allowing ourselves to be devalued. We will share our wards with anyone half decent. We also make the mistake of placing our most inexperienced mental health nurses with our most vulnerable and unwell people on acute mental health wards. Working on an acute unit should be for the most elite and skilled nurses and remunerated as such. People should be trying to show their skills to be allowed onto an acute unit, not doing whatever they can to leave them.
Annoyingly under the heading ‘Psychotherapies’, Cross begins “If you are referred to a psychologist” (p 79), as if Psychologists are the only profession to competently be able to provide talk therapy. Experienced Mental Health Nurses obviously cannot do this. Psychologists have done a wonderful job of making the talking therapies there own. Mental Health Nurses do a terrible job of advancing themselves as a speciality in caring for people with mental health issues.
This is the closest Dr Cross goes from contradicting the what Roy Baumeister would describe as the “Imagined Feminist Ideology”, which he adheres to through out the book. “My females colleagues sometimes have to endure the stress of working with hostile nursing staff who are unused or resistant to working with women doctors” (p 171). I doubt his conclusion of ‘working with female doctors’ is correct. More that 50% of Doctors are female and have been for sometime. Nurses have decades of experience of working with female Doctors. It is not ‘Doctor’ part this is the problem, it is being a female amongst predominantly other females. 90% of nurses are female. Nurses eat their young, and the bullying is mostly done by female nurses. Female bullying is more subtle than male forms. They snub, they exclude, they gossip and proliferate nasty rumours. They keep secrets and withhold information. This well describes working in a predominantly female lead environment. This reminds me of Geoffrey Grief’s observations of female friendships (they are not stable).
Regarding treatment for mental illness: “They are far less traumatising to people who have expressed a desire to change, rather than having change foisted upon them” (p 68). People should be free to choose their treatment and supported in their choices. It leads to better outcomes for them and society. I would include in this the responsibility to cope with the outcomes of these choices. Again, people should be free to make bad choices (even if they are diagnosed as mentally ill).
“The more recent biopsychosocial model acknowledges that mental ill health is likely caused by a combination of biology, psychology, and social factors” (p 185). Mental illness is complex and multivariate and all need to be considered in treatment and the alleviation of the suffering from it. He adds to this with “We are not in a Brave New World scenario of genetic testing of possible mental health conditions prior to conceiving children” (p 198). We are a long way away from the socialist dystopia where every thing was everyone's, including each others bodies (it was the height of rudeness not to have sex with someone who wanted to have sex with you).
Dr Cross writes “I support the growing momentum in mental health to move away from diagnostic classification based on ‘abnormal’ symptoms used to make a diagnosis, to a model that looks at experiences of mental health challenges as variations of the usual human experience” (p 200). I agree with this point. Allen Frances, maybe cynically, suggested most recent DSM-V was written mostly for the benefit of the drug and insurance industries. Anyone who has worked in the industry knows that diagnosis are not scientific. It is a collection of symptoms. It is the symptoms that are important and the individual needs to be treated and worked with those symptoms.
“I have had experience of anguished parents leaving their young daughters in the care of mental health unit staff, only for the daughters to be assaulted or targeted by other inpatients of the service. Specific units focusing on particular mental health challenges or organised for people with specific needs is useful” (p 202). Yes – I have experienced this too. Acute Care wards are not always places of safety where everyone is put together who is suffering from mental illness. Is the potential solution similar to the psychiatric hospitals close in the 1980’s? Back to the Future? “In our system, we don’t have enough inpatient mental health beds for the current need. Similarly, we don’t have enough community support services, which could assist those with moderate to complex needs to gain necessary earlier intervention and support and prevent them from requiring emergency crisis admission” (p 206). I note that it is often the people who complain about the poor state of acute mental health wards and should all be closed, are the same people who say we do not have enough of them (especially if a family member of loved on is not offered a bed). Yes we can do better, and do not throw the baby out with the bath water. I feel the mental health industry in general over promises, and under delivers. We cannot solve your existential problems for you.
Dr Cross extensively quotes the work of RD Laing and Thomas Szass and more contemporaneously Joanna Moncrieff who are seen as part of the Anti-Psychiatry movement. I agree that they have their points which are not well answered by contemporary psychiatry group think. I also think a strength of Psychiatry is that a lot of Psychiatrists will agree with this. Psychiatry will consider challenging thoughts and change practice faster than other disciplines such as obstetrics.
I have always had an issue with the concept of capacity and not ever found a reliable black and white test for judging capacity. When in the grey, decisions around capacity come down to the subjective judgement of a clinician. I have had many a conversation with people who are suicidal and I cannot find a good argument that they do not have capacity (some people truly have dreadful lives that you would not believe). The clinical heuristic is only someone who is mentally ill would want to commit suicide, and do what is within your power to prevent them acting on these thoughts. Cross does a wonderful job in chapter 7 of investigating these dilemma’s and acknowledges the pitfalls and failings we engage in when assessing a persons capacity. Dr Cross has clearly wrestled with capacity and likely has got it wrong in the past (like me). “How a person – whether they’re a police officer, paramedic or mental health profession – understands or defines capacity in an acute situation can be quite subjective, while risk can only really be measured by considering the person’s history in conjunction with their current and potential immediate future state. Issues of capacity and risk mist then be balanced as much as possible against the person’s right to self determination and freedom from coercion, force or constraint” (p 125). It is a balancing act that we get wrong on occasion.
Nurses CARE, and I am familiar with the acronym CARE (cover arse, retain employment). Dr Cross acknowledges this, “a practice that might be dubbed ‘covering you arse’, a humorous take on the acronym ‘CARE’” (p 129). Mental Health is highly risk adverse leading to decision being made from a CARE perspective, rather than in the person’s best interest. Clinicians know what the score is and what happens when taking clinical risks lead to the not hoped for outcome. Clinicians make choices to protect the organisation, not what is best for the person receiving CARE. I have done this myself. I will protect myself at all times. To change this, we need organisations to become more comfortable with adverse outcomes and not engage in what Annie Duke describes as ‘resulting’. Why should a clinician risk their career and family, even when they do not think it will be in the best interests of the person being treated. Until the witch hunts stop, we should all engage in CAREing practice.
Police are asked to do way too much in the mental health sector and they are not mental health clinicians and should only be used as a final resort where there is no less restrictive option. The work that mental health clinicians do not want to do is foisted onto the Police. I like the relatively recent initiatives of pairing mental health nurses with Police for crisis mental health call outs where they work together. It seems to be working and both support Police and people with Mental Illness.
Advanced directives are not useful when a person who is not at immanent risk to themselves or others and may be making poor choices due to being somewhat unwell. People do not always listen to their past self, when they were ‘well’ (and they should be known and referred too). What I do in practice is remind the person what their past self had recommended in their advanced directive, and then do what the present self advises. The reverse is true when the mental health act is being applied, I would have the discussion about what the advanced health directive said (if that was possible) and then do what I believed to be best clinically indicated. Always tell the person what you are thinking.
Trolling and bullying are terms that are not defined in the context of this work and form part of the dichotomous thinking Dr Cross engages in. My experience is that claims of these behaviours are used as tools by trolls and bullies to attack others. Dr Cross recognises “What is more damaging in terms of clinician’ psychological wellbeing and safety at work is the ongoing toll of inappropriate or predatory behaviours. The reporting of narcissists, psychopaths and predators in the profession appears to take ages to resolve, it the issues is even acknowledged in the first place. These people are causing substantial harm to the system, yet they slip through regulatory nets with charming ease and this takes toll the mental wellbeing of others below them in the ranks” (p 177). The narcissists, psychopaths and predators he recognises have great skills in understanding systems and how to leverage them for their own ends. Tools for addressing these people are most effectively used by them to get rid of threats.
See rest of review in comments section.
This book popped up as a suggested read and ticked a lot of boxes. I am interested in the Mental Health System in Australia, having spent most of my career working in it. I agree that we could do better structurally and individually. I wanted to find out about Dr Cross’s ideas and if they had merit and were useful. Some of this review will appear negative and I want to preface this by saying that I agreed with 95% of what Dr Cross wrote. As I read I had ‘yes, but….” moments often when I disagree with the author or when they write something so well I want to remember it for myself. I have not had this many ‘yes, but…’ moments since reading June Singer.
Like Dr Cross, Australia is the third country I have resided in. I lived in Stoke-Newington and worked in Hackney and we are a similar vintage. In spite of this I am not sure I have ever come across Dr Cross professionally, although colleagues have, and say he is a wonderful Psychiatrist and very funny. We have a number of philosophical differences which will become apparent.
Foremost of these is that I found the underlying philosophy toward society of a Rousseauian Romantic (I acknowledged I am Hobbesian in my outlook). Dr Cross has a number of utopian and idealistic suggestions which assume limitless resources, via public funds. Like any good Rousseauian, Dr Cross never mentions, acknowledges or potentially sees the free rider problem within the provision of mental health services. The free rider problem is an economic concept of a market failure that occurs when people are benefiting from resources, goods, or services that they do not pay for. If there are too many free riders, the resources, goods, or services may be overprovided. He ignores the question of how do you identify freeloaders and then what do you do about them? This is something public mental health services only manage covertly in the shadow of the collective unconscious. In Rousseau’s utopia there are unlimited resources for the noble savage to exploit, in the real world there is not. A question I wrestle with is how much responsibility should a state have towards it’s citizens vs how much an individual should have responsibility towards themselves (and suffer the consequences of poor decisions). If you believe in free will, you believe in allowing people to make bad choices and cope with the consequences of those choices in what might be seen as a Neo-Liberal manner.
Another Rousseauian trait is apologising for the sins of others, before the sins of your self. I am not sure what I make of this. Dr Cross writes that as a profession we need to “own up to the abuses of the past and acknowledge the often traumatising mistakes our predecessors made so we can move forward in a healing way” (p 62). I think Dr Cross (like me) should first own up to his own abuses. I have secluded, restrained, and forcibly given people medications (often in the form of an injection) against their will more times than I care to remember. It was never a good or pleasant experience and always occurred in a context. Nobody left these situations without trauma that was not co-created (I would argue against a victim – perpetrator narrative and believe that our lives are co-created). Dr Cross is happy to throw his professional ancestors under the bus without acknowledging his own engagement with practices which are now considered questionable. The closest I found he went to this is “I have had to apologise to colleagues for leaking stress in unhelpful ways” (p 178). I am always interested in clinicians who can specifically acknowledge where they have got it wrong, and what they have learned from it. I am not sure this book is the appropriate forum to do this, but an acknowledgement of specific professional failings reminds us we are human (as were our ancestors engaging in the best practice they knew at that time). To apologise on their behalf seems facile.
Cross repeatedly sets up a straw man in his return to ‘conversion therapy’ when ever he can. I felt it was implied within the mental health industry as being full of zealots wishing to help people ‘pray the gay away’. I have worked in the industry for nearly 30 years and not ever come across conversion therapy being suggested or advocated for (even by my openly Christian colleagues). Cross’s treatment of Conversion Therapy is the epitome of a ‘Strawman’ argument. It is a dog whistle to the imaginary woke mob to provoke outrage amongst them that this is happening. I found Dr Cross repeatedly made strawmen of our religions generally. “In our places of worship, there could be a dramatic change if mental health issues were openly and factually discussed rather then described as demonic possession or as payback for sinful behaviour. Preaching tolerance, love and acceptance from the pulpit would be valuable” (p 200).
Dr Cross did not acknowledge the role of religion as a positive contributor to peoples mental health and the provision of mental health services. A dirty secret of the mental health industry is that one of the best predictors correlated with mental wellness is engagement in a religious community. People who engage in worship seem to be doing something that is protective of their mental health. Is it the values inherent within a religion? Is it the sense of community, relationships, and sense of belonging that is provided? Is it being able to accept your suffering? One thing the mental health industry does not really cope well with is the concept of the soul (and that is why I love Jung, because he leaves room for it). Blaise Pascal's said “There is a God-shaped vacuum in the heart of every [person] which cannot be filled by any created thing.” and he also said “Men never do evil so completely and cheerfully as when they do it from religious conviction.” Religion taken to far can be damaging and that does not mean a life absent from faith is ideal either. Balance in all things, I take a cosmopolitan view of taking what is helpful and useful. I co-read this with C.S. Lewis’s impactful, The Abolition of Man. Even people with Mentally Illness must be held to a moral standard, and holding people to a standard is not a Rousseauian strength. God has to balance mercy with justice. It is the role of mental health clinicians to be on the side of mercy. We would do well to remember our provision of mercy is balanced by the providers of justice.
Sandy Jeffs writes a number of thoughtful and well written segments of the book showing a nuanced understand of issues surrounding mental illness from a consumers perspective. She acknowledged that the old institutions were not all bad and gave credit to the care she received from the nursing staff. It has made me want to read her books in the future. It contrasted the dichotomous thinking that Dr Croos sometimes expressed.
As a mental health nurse, Dr Cross played to my bias that “there was a clear need to recruit more mental health nurses” (p 22). Sandy Jeffs also bemoans the loss of mental health nursing as an apprenticed speciality. I am an ever shrinking part of my profession. As a metaphor, early in the COVID experience, nurses like me were being offered to do a certificate to work in ICU, so if the worst happened I could be an ICU nurse too. The best argument I gave people to get immunised was that I could be their completely inadequate ICU nurse if they became unwell. I respect the skills of my specialist ICU trained colleague. Unfortunately, Mental Health Nursing is not given or recognised with the same respect. Registered nurses think they can be a mental health nurse and ‘go have a break’, and then cower behind experienced mental health nurses when things become difficult, because ‘it is outside my scope of practice’. No Shit Sherlock, and the mental health nurses are complicit in allowing ourselves to be devalued. We will share our wards with anyone half decent. We also make the mistake of placing our most inexperienced mental health nurses with our most vulnerable and unwell people on acute mental health wards. Working on an acute unit should be for the most elite and skilled nurses and remunerated as such. People should be trying to show their skills to be allowed onto an acute unit, not doing whatever they can to leave them.
Annoyingly under the heading ‘Psychotherapies’, Cross begins “If you are referred to a psychologist” (p 79), as if Psychologists are the only profession to competently be able to provide talk therapy. Experienced Mental Health Nurses obviously cannot do this. Psychologists have done a wonderful job of making the talking therapies there own. Mental Health Nurses do a terrible job of advancing themselves as a speciality in caring for people with mental health issues.
This is the closest Dr Cross goes from contradicting the what Roy Baumeister would describe as the “Imagined Feminist Ideology”, which he adheres to through out the book. “My females colleagues sometimes have to endure the stress of working with hostile nursing staff who are unused or resistant to working with women doctors” (p 171). I doubt his conclusion of ‘working with female doctors’ is correct. More that 50% of Doctors are female and have been for sometime. Nurses have decades of experience of working with female Doctors. It is not ‘Doctor’ part this is the problem, it is being a female amongst predominantly other females. 90% of nurses are female. Nurses eat their young, and the bullying is mostly done by female nurses. Female bullying is more subtle than male forms. They snub, they exclude, they gossip and proliferate nasty rumours. They keep secrets and withhold information. This well describes working in a predominantly female lead environment. This reminds me of Geoffrey Grief’s observations of female friendships (they are not stable).
Regarding treatment for mental illness: “They are far less traumatising to people who have expressed a desire to change, rather than having change foisted upon them” (p 68). People should be free to choose their treatment and supported in their choices. It leads to better outcomes for them and society. I would include in this the responsibility to cope with the outcomes of these choices. Again, people should be free to make bad choices (even if they are diagnosed as mentally ill).
“The more recent biopsychosocial model acknowledges that mental ill health is likely caused by a combination of biology, psychology, and social factors” (p 185). Mental illness is complex and multivariate and all need to be considered in treatment and the alleviation of the suffering from it. He adds to this with “We are not in a Brave New World scenario of genetic testing of possible mental health conditions prior to conceiving children” (p 198). We are a long way away from the socialist dystopia where every thing was everyone's, including each others bodies (it was the height of rudeness not to have sex with someone who wanted to have sex with you).
Dr Cross writes “I support the growing momentum in mental health to move away from diagnostic classification based on ‘abnormal’ symptoms used to make a diagnosis, to a model that looks at experiences of mental health challenges as variations of the usual human experience” (p 200). I agree with this point. Allen Frances, maybe cynically, suggested most recent DSM-V was written mostly for the benefit of the drug and insurance industries. Anyone who has worked in the industry knows that diagnosis are not scientific. It is a collection of symptoms. It is the symptoms that are important and the individual needs to be treated and worked with those symptoms.
“I have had experience of anguished parents leaving their young daughters in the care of mental health unit staff, only for the daughters to be assaulted or targeted by other inpatients of the service. Specific units focusing on particular mental health challenges or organised for people with specific needs is useful” (p 202). Yes – I have experienced this too. Acute Care wards are not always places of safety where everyone is put together who is suffering from mental illness. Is the potential solution similar to the psychiatric hospitals close in the 1980’s? Back to the Future? “In our system, we don’t have enough inpatient mental health beds for the current need. Similarly, we don’t have enough community support services, which could assist those with moderate to complex needs to gain necessary earlier intervention and support and prevent them from requiring emergency crisis admission” (p 206). I note that it is often the people who complain about the poor state of acute mental health wards and should all be closed, are the same people who say we do not have enough of them (especially if a family member of loved on is not offered a bed). Yes we can do better, and do not throw the baby out with the bath water. I feel the mental health industry in general over promises, and under delivers. We cannot solve your existential problems for you.
Dr Cross extensively quotes the work of RD Laing and Thomas Szass and more contemporaneously Joanna Moncrieff who are seen as part of the Anti-Psychiatry movement. I agree that they have their points which are not well answered by contemporary psychiatry group think. I also think a strength of Psychiatry is that a lot of Psychiatrists will agree with this. Psychiatry will consider challenging thoughts and change practice faster than other disciplines such as obstetrics.
I have always had an issue with the concept of capacity and not ever found a reliable black and white test for judging capacity. When in the grey, decisions around capacity come down to the subjective judgement of a clinician. I have had many a conversation with people who are suicidal and I cannot find a good argument that they do not have capacity (some people truly have dreadful lives that you would not believe). The clinical heuristic is only someone who is mentally ill would want to commit suicide, and do what is within your power to prevent them acting on these thoughts. Cross does a wonderful job in chapter 7 of investigating these dilemma’s and acknowledges the pitfalls and failings we engage in when assessing a persons capacity. Dr Cross has clearly wrestled with capacity and likely has got it wrong in the past (like me). “How a person – whether they’re a police officer, paramedic or mental health profession – understands or defines capacity in an acute situation can be quite subjective, while risk can only really be measured by considering the person’s history in conjunction with their current and potential immediate future state. Issues of capacity and risk mist then be balanced as much as possible against the person’s right to self determination and freedom from coercion, force or constraint” (p 125). It is a balancing act that we get wrong on occasion.
Nurses CARE, and I am familiar with the acronym CARE (cover arse, retain employment). Dr Cross acknowledges this, “a practice that might be dubbed ‘covering you arse’, a humorous take on the acronym ‘CARE’” (p 129). Mental Health is highly risk adverse leading to decision being made from a CARE perspective, rather than in the person’s best interest. Clinicians know what the score is and what happens when taking clinical risks lead to the not hoped for outcome. Clinicians make choices to protect the organisation, not what is best for the person receiving CARE. I have done this myself. I will protect myself at all times. To change this, we need organisations to become more comfortable with adverse outcomes and not engage in what Annie Duke describes as ‘resulting’. Why should a clinician risk their career and family, even when they do not think it will be in the best interests of the person being treated. Until the witch hunts stop, we should all engage in CAREing practice.
Police are asked to do way too much in the mental health sector and they are not mental health clinicians and should only be used as a final resort where there is no less restrictive option. The work that mental health clinicians do not want to do is foisted onto the Police. I like the relatively recent initiatives of pairing mental health nurses with Police for crisis mental health call outs where they work together. It seems to be working and both support Police and people with Mental Illness.
Advanced directives are not useful when a person who is not at immanent risk to themselves or others and may be making poor choices due to being somewhat unwell. People do not always listen to their past self, when they were ‘well’ (and they should be known and referred too). What I do in practice is remind the person what their past self had recommended in their advanced directive, and then do what the present self advises. The reverse is true when the mental health act is being applied, I would have the discussion about what the advanced health directive said (if that was possible) and then do what I believed to be best clinically indicated. Always tell the person what you are thinking.
Trolling and bullying are terms that are not defined in the context of this work and form part of the dichotomous thinking Dr Cross engages in. My experience is that claims of these behaviours are used as tools by trolls and bullies to attack others. Dr Cross recognises “What is more damaging in terms of clinician’ psychological wellbeing and safety at work is the ongoing toll of inappropriate or predatory behaviours. The reporting of narcissists, psychopaths and predators in the profession appears to take ages to resolve, it the issues is even acknowledged in the first place. These people are causing substantial harm to the system, yet they slip through regulatory nets with charming ease and this takes toll the mental wellbeing of others below them in the ranks” (p 177). The narcissists, psychopaths and predators he recognises have great skills in understanding systems and how to leverage them for their own ends. Tools for addressing these people are most effectively used by them to get rid of threats.
See rest of review in comments section.
September 23, 2024
This book really had me scratching my head and wondering who it is actually FOR. The consumer already knows the pitfalls of the system. It's probably a bit dry for a member of the general population with a passing interest in mental illness. The various different stakeholders already have their take on what is wrong and needs to be done to improve Australia's mental health system. If someone doesn't know Mark Cross they are unlikely to find a lot of his references to his own life interesting. He's not exactly a household name.
A lot of his suggestions have already been put into practice and/ require a lot of money.
He wants billionaires to give money to the cause, but how about HIM giving some money. At least start with the profits of this book (of which I can't imagine there'll be a lot).
I totally support the other review which so eloquently points out major problems with his arguments. At the end of the day he operates a small business from home thanks to Telehealth and his income is derived from Medicare and/ personal financial contributions from those who can afford his services. His days of working in the public and even the private hospital environment seems to be well and truly over. This is reflected in the fact that although he briefly mentions both, Safe Spaces run by peer workers are a huge part of psych emergency rooms now and public patients have been paid for to enter and receive all of the benefits of private admissions nation wide for ages. I'm not saying the system is remotely near ok yet, but Mark Cross misses a lot to the point the book is obsolete.
Which brings me back to the question - who is this book for? It could be beneficial to med students considering a career in psychiatry or those in the early years of specialist training as to 'what to expect' (out of date information notwithstanding). Policy makers aren't going to take much notice as they are already being better informed by the various mental health commissions in the various states as well as the well organized lived experience and carer organisations who are constantly making submissions.
I feel he just had the need to share his thoughts and experiences, but there is nothing really groundbreaking here.
A lot of his suggestions have already been put into practice and/ require a lot of money.
He wants billionaires to give money to the cause, but how about HIM giving some money. At least start with the profits of this book (of which I can't imagine there'll be a lot).
I totally support the other review which so eloquently points out major problems with his arguments. At the end of the day he operates a small business from home thanks to Telehealth and his income is derived from Medicare and/ personal financial contributions from those who can afford his services. His days of working in the public and even the private hospital environment seems to be well and truly over. This is reflected in the fact that although he briefly mentions both, Safe Spaces run by peer workers are a huge part of psych emergency rooms now and public patients have been paid for to enter and receive all of the benefits of private admissions nation wide for ages. I'm not saying the system is remotely near ok yet, but Mark Cross misses a lot to the point the book is obsolete.
Which brings me back to the question - who is this book for? It could be beneficial to med students considering a career in psychiatry or those in the early years of specialist training as to 'what to expect' (out of date information notwithstanding). Policy makers aren't going to take much notice as they are already being better informed by the various mental health commissions in the various states as well as the well organized lived experience and carer organisations who are constantly making submissions.
I feel he just had the need to share his thoughts and experiences, but there is nothing really groundbreaking here.
November 1, 2025
Listen, I totally understand what the other reviewers are saying—who is this book written for? Its approach comes across as way too superficial and grounds itself too much on anecdotal experiences for experts in the field, as opposed to a more detailed evidence-based approach to critiquing the system the author speaks of in the book. However, I do believe this book is great for laypeople who are interested in getting to know how the mental health system works in Australia, mental health students (psychology, psychiatry, or other similar fields) wanting to get a good grasp of the system they'll be working in, or foreign mental health professionals looking to work in Australia. It's quite an innocuous and practical book to have, even if it didn't really give a particularly groundbreaking solution on how to fix Australia's mental health system that already hasn't been addressed in past literatures. And I have to appreciate how empathetic and passionate Mark Cross is in his work—makes me want to become as great of a mental health clinician as he is, if or when I do get to become a licensed clinical psychologist. Either way, it's interesting how much this book makes me, a psychology grad, want to get into psychiatry, lmao.
November 20, 2024
Thanks Dr Cross for your highly informative book on MHC in Australia.
Written by a psychiatrist who has worked both in the UK and Australia, this book begins a huge, much needed conversation on Australia’s mental health system.
It raises so many questions for with me and on a shallow level most always came back to $$$. Having worked in hospitals and LE over the years I have often wondered why Australian doesn’t have mental health hospitals, much like our public hospitals. To me it makes sense, I understand that there is the bilateral mode of mind/body however with public health systems breaking surely mental health can begin to be treated more seriously, less stigmatised and given the preventative attention, through funding that it so desperately needs.
This is a wonderful book, often at times difficult to read and requires a **trigger warning** as there is much discussion of suicide.
Thank you again Dr Cross for bringing this book to us and demonstrating your huge compassion in the speciality.
Written by a psychiatrist who has worked both in the UK and Australia, this book begins a huge, much needed conversation on Australia’s mental health system.
It raises so many questions for with me and on a shallow level most always came back to $$$. Having worked in hospitals and LE over the years I have often wondered why Australian doesn’t have mental health hospitals, much like our public hospitals. To me it makes sense, I understand that there is the bilateral mode of mind/body however with public health systems breaking surely mental health can begin to be treated more seriously, less stigmatised and given the preventative attention, through funding that it so desperately needs.
This is a wonderful book, often at times difficult to read and requires a **trigger warning** as there is much discussion of suicide.
Thank you again Dr Cross for bringing this book to us and demonstrating your huge compassion in the speciality.
January 13, 2025
I found this book very interesting from the point of view of the mother of a teenager with mental health problems. I had no thought that I would ever be at the emergency section of a large public hospital with a young person who had self harmed. I had no idea about how the system worked - or didn’t work. This was complicated by the fallout from Covid. The journey from that first presentation took years and I wonder now whether it need to have done if that magical prescription mentioned by the author - continuity of care - was in place. I highly recommend that Australians read this intelligent and compassionate book and write to the politicians to ask them to read it. I have no doubt that if the problem of mental health was tackled according to the author’s recommendations the country would save a lot of time, money and anguish in the long run.
August 27, 2025
I liked this book and it brought me a lot of comfort! The first few chapters are much more interesting and fun to read than the later ones - which are very general info like wikipedia articles. While necessary, it was a bit introductory and I would have wanted more of an opinion/perspective to be presented. I liked learning about the specific history of Australian mental institutions and what has/hasn't changed. He seems like a nice guy : )
August 30, 2024
Full on subtitle but so apt. Couldn't put this down. Dr Mark Cross explains the complexity and the historical mess of the mental health system in a very accessible way. Our communities need to deeply listen and show more compassion towards people with ill mental health. A hopeful and rich guide on how to do this.
July 25, 2025
An infuriatingly relatable insight into the mental health system. I loved this book and I'll read it again. I've got the physical copy but I listened to the audiobook and Dr. Mark Cross's voice is so soothing he could tell you about something horrific and you'd be okay.
November 2, 2024
5⭐️
having lived this experience, can confirm this is all valid and true
having lived this experience, can confirm this is all valid and true
December 15, 2025
I enjoyed this book and Mark’s writing as a psychology student. He levied some fair accusations on past/present psychiatric tendencies which I liked.
Displaying 1 - 10 of 10 reviews