La música ¿una inteligencia?

It is usual in qualitative research to position the research in relation to person (the researcher) and place (geographic and/or social systems). One aim is to give the reader some context for considering the researcher’s interpersonal presence within the interview and interpretive perspective in approaching the data analysis. A

complementary aim is to provide some relevant particularities of the social context or social systems within which the participants’ experiences took place. In this instance some brief comments about the mental health system in the state of Victoria may be helpful.

5.9.1 The researcher

I came to this project with a background of working as a clinical psychologist. (In Australia Masters qualifications establish eligibility for registration). In the formative years of my professional life I worked in mental health services, including inpatient settings, where in many instances a suicide attempt had precipitated entry to the service. Later I looked back and wondered whether we worked with this experience in the best way we could. I was trained in a psychodynamic orientation and continue to find this the most helpful framework for thinking and understanding, but working in inpatient mental health instilled the need for flexibility and pragmatism in terms of enacted practice. I believe it is important in clinical practice and in qualitative research (and often in everyday life) to be open to however and whatever a person may present, to listen without making assumptions, at the same time recognising that engaging with someone else’s experience involves an emotional as well as reflective response. This project was completed part-time over a lengthy period in parallel with commitment to work and family.

5.9.2 Mental health system context

As in many other countries, the late decades of the 20th century saw Australian mental health services re-shaped by deinstitutionalisation and mainstreaming (Croll, 1995). This section aims to provide a brief overview of the mental health service system in the state of Victoria in the past ten to fifteen years, a period which includes the times of contact with clinical services discussed by participants in this study. The adult mental health system includes public (government-funded, state-run) and private services. The public system includes inpatient units (usually within or co-located with general medical hospitals) and community mental health services which provide on- site outpatient appointments, mobile support teams which visit people (usually with long-term problems) at home or in supported accommodation, and community assessment and treatment teams (CATT). The CATT teams aim to respond to mental health emergencies in the community, making an assessment of whether or not the person needs to be admitted to hospital, and providing crisis support or treatment and referral links to other services. Depending on the nature of the emergency, police and/or ambulance teams may also be involved. Adult community mental health services have guidelines about eligibility for services, aiming primarily to provide services for those with ‘serious mental illness’ (and excluding those whose problems are seen as less serious). Within the public system there are also services for children, adolescents and families (but no participant in the current study spoke of experiences with these services).

The private mental health system consists of private hospitals (often stand-alone facilities) and individual private practitioners – mainly psychiatrists and psychologists – who may be co-located in shared practices. Referral to private practitioner mental health specialists is via primary health care doctors (known as general practitioners or GPs). Australia has a government-run universal health insurance system (Medicare). For decades only medical doctors (including psychiatrists) were covered by the Medicare system, but in the last few years Medicare has extended to psychologists, albeit for a much more limited number of sessions than is the case for psychiatrists. Most commonly the patient pays the practitioner and then receives a rebate from Medicare. Usually there is a gap between the payment made (fee charged) and the rebate, meaning that the patient pays the gap amount. It is also possible for

practitioners to ‘bulk bill’ Medicare directly, in which case the practitioner receives the rebate amount only and the patient does not pay a gap payment. Over time bulk billing has become less common, but some practitioners do this for patients with very limited financial resources. In relation to hospitalisation, private psychiatrists can arrange admitting rights with private hospitals, but have to involve the CATT team if they want to admit a patient to a public mental health inpatient unit. Psychologists do not generally have admitting rights anywhere and also do not have the right (or currently the training) to prescribe medication.

If a person makes a suicide attempt they will be taken to the Emergency Department of a general medical hospital. His or her medical condition will be assessed, treated and a decision made about the need for admission to a ward. When the person is medically well enough, mental health needs will be assessed. If a person in the community is struggling with suicidal thoughts and he or she (or a family member or treating professional) feels a hospital admission is needed, the avenues are to present to an Emergency Department or to call the CATT team. The emergency assessment function of the CATT team means it is the gatekeeper to hospitalisation in the public system. At one level the philosophy around this is that it is better for people to be treated in the community and spend as little time in hospital as possible. However some (e.g., Croll, 1995) have argued that pragmatic issues of bed availability and funding for services play just as big a role in this policy. When a person is admitted to a public hospital, responsibility for treatment moves from the private practitioner to the hospital team, who will also decide on readiness for discharge. Admission to a private hospital gives the psychiatrist (and hence potentially the patient) more control over length of stay. However private hospital admissions are not covered by