Compared with what - by Kym Mcminn

Compared With What?

A question our mental health system needs to answer.

I have walked alongside people experiencing profound psychosis, overwhelming voice-hearing experiences and other distressing perceptual disturbances.

Not only through my work as a nurse and now leading a psychosocial disability service, but beside someone I love most - my own son.

There is a profound difference between understanding psychosis professionally and living alongside it as a parent.

I have had the privilege - and at times the heartbreak - of experiencing both.

Not from behind a desk. Not by reading clinical notes. But sitting beside someone in emergency departments at two o'clock in the morning. Holding space while they tremble with fear. Helping them find enough safety to get through the next five minutes. Providing reassurance as voices tell them they deserve to die. Watching someone become terrified by people they believe are standing outside the room, convinced someone is coming to hurt them.

Watching them respond to people you cannot see. Listening as they desperately try to make sense of experiences that have become all-consuming.

It is not our role to argue with someone's experience.

To them, it is real. The fear is real. The distress is real. The suffering is real.

Our role is to create enough safety that they can make it through the next moment. To stay beside them while the distress settles.

To help them reconnect with the people around them. To remind them they are not alone.

Those moments stay with you.

And increasingly, so does one sentence I continue to hear from Area Mental Health services - not just in my local region, but across Victoria.

"We have determined that the potential harms of an inpatient psychiatric admission outweigh the potential benefits."

Every time I hear those words, I find myself asking the same question.

Compared with what?

Before anyone misunderstands where I'm coming from, let me be clear. This is not an argument that everyone experiencing mental illness should be admitted to hospital. In fact, I believe exactly the opposite.

The organisation I founded exists because we believe recovery happens in homes, communities, relationships, employment, purpose and connection - not hospital wards. Our team works incredibly hard to prevent unnecessary admissions. We've supported people who once cycled repeatedly through emergency departments and inpatient units to build lives where admissions became rare.

We've reduced reliance on crisis services. Helped people reconnect with family. Find housing. Reduce substance use. Return to education and employment. Rebuild purpose. Regain hope.

Hospital should absolutely be a last resort. But a last resort is still a resort.

I have advocated alongside many people experiencing acute psychosis.

Different ages. Different diagnoses. Different life stories.

Some have experienced significant trauma. Some have used substances. Some have never used drugs or alcohol in their lives. Some hear voices. Some experience visual hallucinations. Some become convinced people are trying to kill them. Some smell things nobody else can smell. Some feel hands on their body when nobody is there. Some reach a point where they can no longer confidently distinguish between their internal experiences and the people physically standing beside them.

What many of them have had in common is this.

They recognised they were becoming more unwell. They asked for help. Sometimes they asked specifically for a voluntary admission because they no longer felt safe managing what they were experiencing.

Many had already done everything we ask people to do. They reached out early. They engaged with services. They participated in rehabilitation.

They attended appointments. They accepted support. Their families advocated. Treating teams were contacted. Emergency departments were attended - sometimes repeatedly.

And yet we have increasingly heard the same explanation.

"We have determined that the potential harms of an inpatient psychiatric admission outweigh the potential benefits."

Psychosis doesn't become less frightening simply because someone has experienced it before. Commanding hallucinations don't become less dangerous because they occurred last month as well. Persecutory beliefs don't become less distressing because they are familiar to the treating team.

In fact, one of the greatest risks in mental health care may be this:

The system's familiarity with someone's distress can quietly become confused with that person's safety.

Someone can have a long history of mental illness and still experience an acute deterioration. Someone can live with chronic risk and still enter an acute crisis.

Those two things are not mutually exclusive.

Yet I sometimes wonder whether our familiarity with repeated presentations has unintentionally dulled our sense of urgency.

This raises a question I believe our mental health system urgently needs to answer.

When we say that the potential harms of admission outweigh the benefits...

Compared with what?

Compared with repeated discharge? Compared with expecting families to carry the risk? Compared with asking community providers to bridge the gap? Compared with hoping tomorrow will somehow be different? Every healthcare decision involves weighing risks. Surgery carries risks. Chemotherapy carries risks. Intensive care carries risks. Psychiatric admission carries risks too.

But in every other area of healthcare, we weigh those risks against the risks of not intervening.

Why should mental health be any different?

During my nursing training, I was taught that psychosis is a psychiatric emergency.

Why?

Because the longer psychosis goes untreated, the poorer a person's long-term outcomes are likely to be.

Research consistently shows that a longer duration of untreated psychosis is associated with poorer recovery, greater functional impairment and a lower likelihood of remission.

Researchers continue to debate exactly how psychosis affects the brain biologically.

But there is broad agreement on one thing.

Early intervention matters.

That's why Early Psychosis services exist. That's why families are encouraged to seek help as early as possible.

That's why clinicians are trained to identify deterioration quickly. So why does that urgency sometimes seem to disappear once someone is already known to the system?

Why isn't the risk of ongoing untreated psychosis discussed with the same urgency as the potential harms of admission? Why aren't we asking whether repeated discharge carries risks of its own? Because surely those risks deserve equal consideration.

Every clinician is trained to undertake a risk-benefit analysis. Yet increasingly, I wonder whether we're only talking about one side of the equation. We speak about the risks of admission. We rarely speak with the same urgency about the risks of non-admission. Delayed treatment. Repeated crises. Repeated emergency presentations. Lost opportunities for recovery.

Those harms deserve equal weight.

From everything I have researched, there is evidence that some psychiatric admissions - particularly prolonged, coercive or poorly planned admissions - can themselves be harmful. There is also a clear legislative emphasis on providing the least restrictive care possible.

I support that. Most clinicians I know support that. Nobody wants to return to a time when hospital was the default response to every mental health crisis.

But there is an important distinction that I fear we are beginning to lose.

The Victorian Mental Health and Wellbeing Act asks clinicians to consider the least restrictive effective option.

Not simply the least restrictive option.

Those are two very different things.

Because the least restrictive option is only truly the least restrictive if meaningful treatment still exists on the other side of that decision.

If hospital is not the answer...

What is?

And is that alternative genuinely available at two o'clock in the morning, on a Sunday, when someone is terrified by what they are experiencing?

There is a difference between chronic risk and acute deterioration.

Many people we support live with chronic suicidal thought. Many live with persistent voices. Many experiences ongoing psychotic symptoms. Those experiences may be longstanding. But longstanding does not mean stable.

And familiar does not mean safe.

Someone can have experienced psychosis for years and still experience an acute deterioration requiring a completely different level of intervention.

A person living with schizophrenia who develops commanding hallucinations directing them to harm themselves or others has not simply become "their usual self." Something has changed. Likewise, someone who recognises that change, seeks help, and voluntarily requests admission is demonstrating something we consistently encourage in mental health care: Insight. Help-seeking. Shared decision-making.

So why does it sometimes feel as though the person's own understanding of their deterioration carries so little weight?

If we genuinely believe in person-centred care, recovery-oriented practice and shared decision-making, shouldn't a person's own recognition that they are no longer safe be an important part of the clinical picture?

Increasingly, disability support providers are being expected to fill gaps that belong within the public mental health system.

On more than one occasion, following psychiatric assessment, responsibility has effectively been handed back to NDIS-funded supports.

We have been expected to "manage" escalating psychosis in the community.

Let me be very clear. Support workers are not psychiatrists. They are not psychiatric nurses. They do not prescribe medication. They do not diagnose.

They do not provide inpatient psychiatric treatment.

They provide psychosocial support. Those roles complement clinical care.

They do not replace it.

Every time acute psychiatric care is shifted onto community disability providers, everyone loses.

Support workers are asked to carry risks they were never trained, funded or legislated to manage. Families are left frightened and exhausted.

And the person experiencing psychosis is left in the middle of a system where everyone cares - but no single service can provide what they actually need.

The NDIS was never intended to replace the public mental health system.

Yet increasingly, it feels as though community providers are being asked to absorb responsibilities that rightly belong within specialist mental health services.

This isn't a criticism of individual psychiatrists. Nor is it a criticism of emergency clinicians or mental health nurses. Many of them are working under extraordinary pressure. Bed shortages are real. Workforce shortages are real. Demand has never been greater.

I have worked alongside psychiatrists, nurses and clinicians whose compassion, advocacy and clinical judgement have changed people's lives.

My concern isn't with those individuals. It's with the system they are trying to work within.

Because we need to ask another uncomfortable question. Are some decisions now being driven primarily by clinical evidence? Or are they increasingly being shaped by system capacity?

Those are not the same thing.

If the answer is capacity, then let's have an honest conversation about capacity. Let's acknowledge the realities of workforce shortages. Let's acknowledge bed pressures. Let's acknowledge that community alternatives are often limited or unavailable.

But let's not confuse a lack of resources with evidence that hospital is inherently more harmful than the alternative.

They are different conversations. And they deserve to remain different conversations.

One of the phrases we hear repeatedly in mental health is "least restrictive."

It is an important principle. It protects people's rights. It protects autonomy. It protects people from unnecessary coercion.

But I would argue there is another principle we should never lose sight of.

Least restrictive should never become least responsive.

If the least restrictive option leaves someone cycling between emergency departments, returning home in escalating psychosis, presenting again days later, and repeating that cycle over and over...

We have to ask ourselves whether it is truly the most therapeutic option. Or simply the only option the current system has capacity to offer.

Because those are not the same thing.

History has taught us something important.

Australia rightly moved away from large psychiatric institutions because many people experienced neglect, abuse and inhumane treatment.

Closing those institutions was necessary. Nobody wants to return to that model. But closing something is only half the job. You have to replace it with something better.

Have we?

Or have we gradually shifted responsibility elsewhere?

Onto emergency departments. Onto police responses. Onto homelessness. Onto exhausted families. Onto carers. Onto disability support providers. And, ultimately, onto the very people experiencing mental illness themselves.

Somewhere along the way, it feels as though responsibility has slowly drifted away from the system specifically designed to respond to acute mental illness.

Psychiatric admissions may be harmful. Sometimes they are.

Poorly planned admissions. Coercive admissions. Traumatising admissions.

They deserve scrutiny.

Every part of our mental health system should be open to scrutiny.

But surely the answer isn't fewer therapeutic options. Surely the answer is better ones.

If institutions failed because they were harmful...

And now psychiatric admissions are increasingly described as harmful...

What's next?

Do we continue reducing access to inpatient care? Or do we finally invest in making inpatient care worthy of the people who need it?

Trauma-informed. Recovery-oriented. Compassionate. Therapeutic. Safe.

Places where people experiencing acute psychosis are met with dignity instead of fear. Places where recovery begins - not simply where risk is managed.

Because the answer to poor psychiatric care cannot simply be less psychiatric care.

It has to be better psychiatric care.

Community psychosocial support works.

I know it works because I've seen it.

My team has supported people who previously cycled endlessly through emergency departments to remain safely in the community.

We've reduced admissions. Reduced crisis presentations. Reduced reliance on acute services. Helped people reconnect with family. Find housing. Gain employment. Reduce substance use. Build relationships. Rediscover purpose.

These outcomes don't happen by accident.

They happen because community support, delivered well, changes lives.

But community support also has limits.

There comes a point where the safest, most therapeutic response is no longer something that can be provided by disability support workers, peer workers, families or carers.

There comes a point where specialist mental health care is needed.

Recognising that point isn't failure. It's good clinical judgement.

Every time my team contacts Area Mental Health, it is after exhausting almost everything available to us.

We don't call because it's convenient. We don't call because we haven't tried. We call because we have reached the limits of what community support can safely provide.

When we finally say

"We've exhausted every community option."

When the person themselves says,

"I don't feel safe anymore."

"I think I need more help."

That shouldn't be the point where responsibility is handed back to community providers.

That should be the point where the mental health system does what only the mental health system can do.

I didn't write this because I believe every person experiencing psychosis should be admitted to hospital.

I wrote it because I believe every person deserves a genuine assessment of what is safest for them - not simply what is most achievable for the system.

If we have reached a point where hospital is no longer considered the right answer, then we owe people something better than repeated discharge.

We owe them an alternative that is real. Available. Accessible.

Capable of providing the level of care they need when they need it most.

The answer doesn't have to be hospital every time.

But it has to be something.

Because discharge is not a treatment plan.

This isn't about winning an argument. It's about asking a question.

One that I believe deserves honest discussion from clinicians, policymakers, researchers, carers, peer workers and the broader community.

If we are increasingly saying that hospital admissions can do more harm than good...

How rigorously are we examining the harms of the alternative?

Because every decision carries consequences.

Hospital carries risks. Discharge carries risks. Delayed treatment carries risks. Repeated crises carry risks.

Repeated emergency department presentations carry risks. The longer someone remains without effective intervention, the greater the opportunity for recovery that may be lost.

Every one of those risks deserves to be part of the conversation. Not just the ones associated with admission.

The people we support don't expect perfection.

Neither do I.

They simply deserve a system that responds to acute psychosis with the same urgency and seriousness afforded to every other acute health emergency.

They deserve a system willing to ask difficult questions. Willing to challenge its own assumptions. Willing to continuously improve.

Because if our answer to acute psychosis is no longer hospital...

Then we have a responsibility to build something better.

And until we do, the words,

"The potential harms of an inpatient psychiatric admission outweigh the potential benefits."

should never become the end of the conversation. They should be the beginning of a much harder one.

One that asks not only whether hospital can cause harm...

But whether, in our efforts to avoid one kind of harm, we have unintentionally become willing to accept another. One that asks whether the least restrictive option is also the most therapeutic.

One that asks whether our mental health system is providing the care people need...

Or simply the care it currently has capacity to provide.

And perhaps the most important question of all...

Compared with what?