That there is a mental health crisis in contemporary society is now taken as a commonplace in the official research. Four in ten adults (39.3 per cent) present symptoms of anxiety or depression, with this figure up 7 per cent (from 32.3 per cent) from two years ago. More, experts say younger people are especially vulnerable. According to a Lancet study led by Patrick McGorry, the mental health of those aged between twelve and twenty-five is being undermined by ‘global political, socioeconomic and structural megatrends driving psychological distress, including the rise of social media and the threat of climate change’. A new report decoding a decade of insurance data has found a 732 per cent increase in the rate of Total and Permanent Disability claims for mental health for thirty- to forty-year-olds during the past decade. Angst is all about. The word ‘crisis’ is on repeat. What these phenomena actually are is a complex question. But governments, in developing new strategies for dealing with contemporary social life, are taking for granted that it is a series of individual problems. This has prompted programs that use a ‘retail’ model.
What is to be done? The Victorian suicide prevention framework 2016–2025 has an answer: what is needed is to ‘build resilience’. This approach has common-sense appeal, but the instruction to militarise the self—to patrol one’s boundaries, to operate strategically—has compelling critics.[1] Another response is to offer shop-front treatment to each individual with a disorder. Towards this end, a super-sized cohort of practitioners could be mobilised to treat those who are afflicted. Two local programs offer a chance to consider the viability of a retail approach to intervention.
Designed for twelve- to 25-year-olds ‘going through a tough time’, Headspace has 154 sites across Australia that provide ‘early intervention mental health services’. Funded by the Australian government, it is staffed by salaried employees and is a ‘one-stop-shop’ for face-to-face, online and phone support. If this generic program was up-scaled to offer services to the whole population, what would be needed? A broad-strokes calculation follows.
Headspace states that ‘Two in five young people have experienced a mental health disorder in the past 12 months’. Given there are around 4.3 million Australians in the twelve to twenty-five age group, it follows there are approximately 1.7 million young people in need of care each year. If this figure is compared with the average number of people who have at least one ‘occasion of service’ with a Headspace Centre—867,000 since its establishment in 2006 (5)—it follows that the annual throughput must be, say, 50,000 clients (867,000 divided by 18). On this rough calculation, Headspace is having some kind of contact with around 3 per cent of the group it contends is in need. The Headspace model, on its own terms, is either intended as a boutique model for self-selecting clients, or would require vast up-scaling: an additional 2000 staff to deal with a pool of 4 million troubled people, on a broad-strokes calculation.
If the 2018 figure (268 Effective Full Time staff) is used as a base—Headspace no longer appears to publish its staffing numbers—and this is figure is multiplied by two as a proxy for the many additional Headspace centres now in operation, it has approximately 500 current staff. On the above throughput figures, these staff could be expected to have had contact with, say, 5 per cent of the in-need population. On this account, Headspace would need to grow around twenty-fold (that is, 2000 per cent) to meet current demand. If the target group was broadened from twelve to twenty-five to include the entire population over twenty-five, it would need to consider offering services to around 18 million people. At four times the total for the twelve to twenty-five age group (4 million clients, or 40 per cent of 18 million), an additional 2000 staff would be needed. This response is fantastical in its scale. Like what happens when a small child is given a hammer, the insider’s temptation is to do more of the same—just ‘ther-up’ more individuals—but this would miss the forest for the trees.
Rough arithmetic would therefore seem to exclude a retail response. Key prior questions only thicken this conclusion. The retail shop-front approach of Headspace is clearly designed to break down the barriers presented by clinical offices, and to use a form—the shopping milieu—that is now the dominant form of social interaction. That Headspace’s model deliberately aligns with this form of individualised service has been confidently reiterated by Board Chair Ben Shields: ‘it is encouraging to know so many young Australians trust Headspace to help them navigate challenging times’.
Is Headspace working, on its own terms? Early intervention and preventative programs are notoriously difficult to evaluate. For example, if the ‘stressor’ is contextual in nature—say, climate collapse and social media—is staying at school longer, or reporting oneself to be happier, a reliable indicator of long-term success? This concern is only heightened as models of treatment continue to present concerns with respect to their effectiveness even in the short term. One recent, highly respected meta-study reported that there has been almost no shift in the effectiveness of one-on-one therapy over the last fifty years with respect to anxiety, ADHD, depression or conduct problems.
But a review of a second retail approach, the federal government’s Better Access Program, documents this exact issue. Unlike the Headspace example, in which staff are salaried, the Better Access Program subsidises private practitioners by giving ‘Medicare rebates to people with ‘an assessed mental disorder, so they can access appropriate mental health care’. The scale of the program is enormous: ‘In 2021 … one in 20 received at least one session of psychological treatment’. With 5 per cent of the adult population in tow, the program’s official evaluation states:
it is worrying that consumers experience deterioration in their mental health in not insignificant numbers of (treatment) episodes, and that some show no change. These consumers are most likely to be people who began their episode with relatively mild symptoms or high levels of functioning or satisfaction with life.
However they are spruiked, even treatment programs based on the supposed gold standard (Cognitive Behavioural Therapy) are subject to the same critique Hazenfeld and English levelled half a century ago: that the technology in all people-processing services is ‘indeterminate’, whether the setting is corrections, education or psychiatry.[2] The Better Access evaluation noted: ‘Approximately one quarter to one third experienced significant deterioration over the same (treatment) period (22–32%), depending on the measure’.
In the Better Access Program evaluation one reads of recipients receiving generic ‘psychological treatment’. This phrase begs the question whether this ‘treatment’ necessarily targets an ‘assessed mental health disorder’; one can undertake ‘psychological therapy’ without this being treatment for a ‘disorder’. In practice, perhaps there is little distinction between ‘supportive counselling’ and ‘psychological treatment?’
Generally, the evaluation argues by assertion: the object of attention is ‘mental disorder’ or ‘mental health conditions’. More obliquely, it makes this case by routinely embedding illness-related terms such as ‘prevalence’ and ‘symptoms’. At a second level, the object ‘mental disorder’ / ‘mental health condition’ is consistently conflated with ‘psychological distress’. This illogical situation is (unknowing?) documented in the report itself by the ‘finding that some consumers presented in the ‘“normal range” … [which] may suggest issues relating to the threshold and [the] appropriateness of referral require review’.
The use of a retail model tends to reinforce two aspects of modern treatment: the tendency to individualise conditions, and the tendency to respond to active consumer demand in assigning treatment.
As the report documents: ‘Better Access is certainly serving some groups better than others, and these gaps are widening. Of most concern, increases in utilisation over time disproportionately favour people on relatively higher incomes in major cities’.
Those with multiple and complex needs require wrap-around, team-based services. With rare exceptions, private therapists recoil from this work. Rather than governance arrangements that engage with this complication, private practitioners are allowed to operate without constraint as soon as a GP has made a referral. In this situation it is no wonder therapists gravitate to working with individual and private clients presenting with a form of self-understanding that draws on the retail model—the psychological version of the laissez-faire arrangement.
The shop-front retail model can be seen as an unwitting extension of the private clinical model. The emergence of ‘single-session therapy’ was founded on the idea that the relationship between treatment and improvement is not ‘dose related’—that more sessions do not mean proportionately greater improvement.[3]
Treatment is an uncertain and interactional process. It is not like a pallet of goods that can be impersonally delivered. Great care is therefore needed to be reflective about the frame that is being used to guide understanding, as this heuristic inevitably co-constitutes what is ‘found’. To say the least, ‘illness’ is not always a fit-for-purpose framework, especially for mild to moderate presentations where there is an unstable relationship between what is judged to be out of order and what is acceptable. At this locus of uncertainty, it is especially important not to conflate everyday struggle with illness, psychic discomfort with worrying deviance. This can be iatrogenic by making the presenting problem worse.
It would seem to be at least arguable that the ‘retail turn’ in government-authorised psychological treatment will extend the medicalisation of everyday life far more than have previous models. This could be disastrous. For example, the Headspace website’s section ‘for professionals and educators’ names its program to extend mental health awareness, conducted with Beyond Blue, ‘Be You’. Does this help by talking the contemporary language of self? Or does it inadvertently monger a preoccupation with illness labels and pathologising definitions of identity?
Similarly, if we are told we can aspire to authenticity—that we are imposters until we claim our true selves—then in so much this script is taken on board, are young people being drawn into an interminable quest, de Montaigne’s ‘descent down the spiral staircase of the self’? In a time where so much seems ‘groundless’, hanging out to discover the true me generates what might be termed identity fetishism.
Whatever the virtues and uses of retail therapy, surely it would be better to teach that each of us lives in an indeterminately extended period where multiple external adversities are pressing in on us. Whether acknowledged or not, these discontents enter our inner worlds. In engaging with this interdependence it seems preferable to normalise, rather than pathologise, the struggles that create our inner life experiences if programs are to be effective in the shopping mall of contemporary life.
[1] Soraya Chemaly, The Resilience Myth: New Thinking on Grit, Strength, and Growth After Trauma, New York: Simon and Schuster, 2024; Nikolas Rose. and Filippa Lentzos, ‘Making us resilient: Responsible citizens for uncertain times’, in Competing responsibilities: the ethics and politics of contemporary life, Susanna Trnka and Catherine Trundle (eds), Durham: Duke University Press, 2017, pp 27–48.
[2] Yeheskel Hasenfeld, Human Service Organizations, Pearson: New York, 1982.
[3] Jeff Young, 2018, ‘Single-session therapy: The misunderstood gift that keeps on giving’, in Single-session Therapy by Walk-in or Appointment: Administrative, Clinical, and Supervisory Aspects of One-at-a-time Services, Michael F. Hoyt, Monte Bobele, Arnold Slive, Jeff Young and Moshe Talmon (eds), New York: Routledge, pp 40–58.