Opinion piece on the Royal Commission into Victoria's Mental Health System

Wallpapering over the cracks – a useful metaphor for the work of mental health services?


I would not ordinarily feel moved to write an opinion piece but the advent of the Royal Commission into Victoria’s Mental Health System seems to have evoked something as I write this approaching my 40thbirthday. Perhaps the perfect storm of existential conflict and reflection have coincided in some way to spur me into action. For those of you reading this outside Australia, a Royal Commission is a formal enquiry into a defined public matter of concern. The chair and those supporting them are appointed by the state or federal government.


Putting forth an opinion is a provocative gesture. In a climate of populism, fake news and communication via social media people opine freely with minimal consideration for their audience. Expression of opinion, just like art provokes a flow of emotion between subject and object (and by definition a stirring of both internal worlds). It evokes a response in the other which is either expressed or repressed. In philosophy, the toing and froing of opinion forms the basis of the theory of dialectics but in reality, thesis and antithesis do not neatly converge in an iterative manner toward synthesis. The urge to express opinion occurs in context and is usually related to pent up emotion within a person. Opining can be accompanied by a sort of catharsis akin to lancing a boil hence I write this piece in an attempt to release pent-up angst and frustration related to working in a system with which I feel dissatisfied much of the time. Confining it to writing will hopefully allow me to tread the fine line between opinion and rant. 


I am used to writing in fairly cautious language where I deliberately refrain from expressing opinion. If I do express opinion, it is justified with the support of evidence or I have to self-assure that there is minimal chance that my opinion could cause offence. This is the case when writing psychiatric reports, in communication with colleagues or when writing a scientific paper where every idea or concept needs to be referenced and personalisation is discouraged. Perhaps hypocritically (but hopefully common to most people), I express my opinions freely at home or at work when I am sure that I am not “on record” because it feels “safe”. In the interests of objectivity, I feel compelled to disclose my “conflicts of interest”. As I am expressing opinion, these would include personal facts that may contribute to formation of my opinions. In no particular order, these are: 


·      That I work in healthcare management and as a psychiatrist in both public and private sectors (and earn a very good living from this work). I have worked in the field for the past 14 years. I love my work, so much so it has probably subsumed a large proportion of my identity. I see myself as social psychiatrist. 

·      That I come from a working-class background and am a gay man. 

·      That I am a migrant in Australia (albeit a white British one)

·      A disclosure that I’ve had some difficulties with my own mental health over the years. 


Most of the opinions put forth below are not original and include ideas borrowed from well-articulated theories from the various scientific and humanistic fields. I work in medically-led components of mental health service hence the focus on the concept of mental disease. I am cognisant that other non-medically led models operate in other areas. 


Metaphors are useful when attempting to embrace complex concepts or systems and one that often comes to mind when considering the role of mental health services is the endeavour of “wallpapering over cracks” (cracks in society and within people i.e. within the walls of the psyche). A variety of tools are used to do the work ranging from formation of a therapeutic relationship, taking medication and leverage right through to coercion, threat and interpersonal violence. A common experience for mental health workers involves attempts to wallpaper over cracks with the inevitable appearance of more. The work can sometimes feel like a thankless task and can evoke futility but like all great endeavours it is an iterative process akin to creating a work of art. We use hope, optimism and teamwork to wallpaper over our own cracks and other less favourable emotions often emerge. The mental health system in its current form can sometimes feel punitive, coercive and harsh yet it manages to provides good quality and compassionate care. Many people get their needs met and feel satisfied with their care. However, I am often left thinking that this is done in an unnecessarily complicated manner.




The current state 


Psychiatry is a relatively young medical specialty dating back just over 200 years. Interestingly, it has grown up alongside post-colonial Australia. One of the main contributions that psychiatry has bestowed on society is the concept of “mental disease”. Many other concepts associated with psychiatry (administration of psychotropic medications, procedures intended to change behaviour, coercion, containment, etc.) were actually around, albeit in other forms long before the advent of psychiatry. I use the term “mental disease” as opposed to mental illness or disorder because the concept that has emerged within psychiatry is closer to the formal definition of disease (see below).


“a disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury”


The persistence of the mental disease concept suggests that it serves a purpose of some kind. An ingenious smoke-and-mirrors scenario exists whereby labelling a person with mental disease seemingly sanctions following process:


1.   Human suffering, bad behaviour and moral breaches are selectively split off and described as “psychopathology”. This in turn can be attributed to defects in a person’s brain (called mental illness within the Mental Health Act and defined as “a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory”). 

2.   Social causes are acknowledged as contributory (but are said to act via injuries to an already diseased brain). 

3.   Sometimes spurious links are made between mental disease and potential harms to satisfy legal criteria within the Mental Health Act. 

4.   Families can be absolved of blame because the person has a diseased or dysfunctional brain.

5.   Autonomy and individualism are celebrated as cornerstones of modern society but are coupled with an expectation of personal responsibility. Any change to this would be deemed challenge to our “way of life” so we accept it as a constant in the equation (“that’s just the way it is”). A possible exemption from personal responsibility is the concession that one has mental disease. 

6.   The cause of mental disease is purported to be “complicated” involving some sort of mix of genetic susceptibility, dysfunctional neurones and brain chemistry. We are told that scientists are working diligently to solve this conundrum but for now, we have to make-do with what we have. 


The mental disease concept unravels when you scratch the surface yet professionals and society seem to like it perhaps because it has the appearance of being a potentially solvable problem. It gives us something to fight against and satisfies humanistic desires for order, equilibrium and taxonomy. I am not implying that the concept has been contrived with sinister intent (e.g. as part of a government conspiracy) although one would be forgiven for thinking that is was. When patients make this sort of observation they are often told their opinion is delusional. 


Many within the field of mental health state that the disease models have been an effective banner for advances in medicine. For example, cancer (which is actually a diverse range of diseases with a similarly diverse range of aetiologies) has attracted iconic status with funds, esteem and public sympathy flowing towards it. We hear statistics boasting increases in life expectancy for the entity known as cancer. It is not surprising that the field of mental health looks toward cancer and collectively thinks “we’d like a piece of that”. However, many would argue that the amount of human suffering associated with cancer has not changed over the years. If anything, it has increased along with the plethora of costly, complex and heroic treatments that are offered. Moreover, the diseases that fall within the rubric of cancer have well defined pathologies and are universally caused by out-of-control cell replication. This is not the case with “mental disease”. Taxonomies and dichotomies are pleasing because they allow us to split things off along with any bad feeling. This extract from Wordsworth’s The Prelude sums this up well: 


“In weakness, we create distinctions, then 

Deem that our puny boundaries are things 

Which we perceive, and not which we have made.” 


Scientific advances based on the mental disease model have been modest at best. Developments in psychopharmacology, psychology, neuroscience and genetics have been more impressive but they do not appear to correlate with mental disease entities. This has been partially acknowledged within the field of mental health research such that diagnostic classifications are now being sidelined to consider human behaviours and symptoms on a continuum with “normal”. Evidence that a disease process akin to a form of cancer rears its ugly head and causes aberrant cellular processes leading to illnesses such as schizophrenia, bipolar illness or personality disorder is conspicuously absent. 


The public-facing, post-modern narrative of mental health services is of a successful transition from asylum-based care to care delivered within the community. This movement has coincided with a change in the practice of organised religion within society. The unfortunate reality is that those who would have resided or been treated in asylums now live in rooming houses, the poor end of town or are homeless. Religion has moved into the realm of running non-governmental organisations (NGO’s) and in direct provision of healthcare. Some of the “walk-in” care previously furnished by the church has been replaced by mental health services, NGOs and is increasingly obtained online. Alcohol and drugs are so accessible that these often comprise part of self-directed treatment for many people. 


Psychiatric wards operate so-called “acute care models” and there are few long term supported residential placements affording asylum (in the true meaning of the word). Psychiatric wards are often pressure cookers where a harsh version of the medical paradigm operates - one that subliminally communicates messages such as “take this (medication)”, “behave this way” and “don’t say that” all delivered in a locked setting. So-called “restrictive interventions” involving seclusion (essentially being left alone in a small, locked room often with no toilet), being tethered to a bed and the injection of medication whilst being held down (usually by security guards) are relatively common. Emergency departments, medical wards and dementia units around the state also deliver restrictive interventions under the auspices of “duty of care” if patients do not comply with what is deemed to be in their best interests. Whilst the practice of seclusion and restraint are recorded for those subject to the Mental Health Act, restrictive interventions in other settings are largely unmonitored. 


Hence mental health services become enmeshed in a complicated merry-go-round of causation which ultimately falls in the lap of the person labelled as having mental disease. They are asked, persuaded, leveraged or coerced to take “treatment” of varying kinds – being spoken to, contained or drugged. “Do this”, “behave this way”, “take this and get better” are intimated. Not surprisingly such demands are sometimes met with a negative response and we are back to point (1). If treatments prove ineffective, people are seen as “treatment resistant” and may be offered sympathy and support. If they do not co-operate with the process above they are said to be non-engaging, lacking insight or having impaired capacity. The merry-go-round serves professionals (getting paid, deriving esteem), families (absolved from blame), society (defective members are split-off and labelled as such) as well as politicians. Unfortunately, it does not serve those labelled with mental disease well although it is argued that they obtain care and social support. However, these gains are conditional.


The concept of mental disease serves an unstable foundation for the practice of mental health and many of its initiatives, movements and brands. The Early Intervention in Psychosis movement created a brand that conjures up images of intervening early and preventing a dreadful disease process in vulnerable young people. Forensic psychiatry purports to diagnose and treat similar disease processes that cause people to enact heinous crimes. Similar narratives have been created for maternal mental health, children’s mental health and more recently in the field of pharmacogenomics. Perhaps the most widely publicised misuse of mental disease branding has been by pharmaceutical companies who have marketed drugs purporting to make people feel, think and behave better. We are all aware of the adverse consequences and huge financial gains that accompanied this excursion.


These are of course the outward faces of the brands outlined above which are presented to funders, commissioners and society. It is worth considering what is subliminally conveyed to the recipients of these models of care “back stage”. Behind the image of a helping, healing hand are messages such as “let me help you this way”, “take this”, “consider your feelings as part of a mental disease”, “talk less about that”, “feel like this” and “don’t do that”. Some of these messages are strikingly similar to those in religious indoctrination. 


The mental disease concept has been advantageous. It has diverted some of the workforce and resources within healthcare to forms of human suffering that are not accompanied by specific bodily pathologies. I am consistently amazed by mental health workers who go above and beyond with the aim of helping and healing those who are suffering. They are essentially taking a leap of faith and have confidence that the person they are working with will get better. This is in no small part due to their faith in the concept of mental disease. It allows us to put up a fight against a disease process and present a unified front regardless of which discipline we are trained in. A simplified model for considering human suffering may be necessary or else we are left to embrace too much complexity which could overwhelm or evoke cynicism. The underlying fear may be that if things seem too complicated we may give up, lose faith and stop trying. Mental disease is possibly a modern-day correlate for what would have previously been labelled “bad” or “evil”. Bad and evil necessitate punishment, forgiveness or religious explanations whereas mental disease requires treatment. As Freud set out in Totem and Taboo, all modern forms of socialisation are shaped by primitive culture. 


It is not surprising that our mental health system conveys many of the same messages that are subliminally disseminated in society via political movements, tax regimes, policing, etc. Work hard, keep a stiff upper lip, stay on the “straight and narrow”, don’t bite the hand that feeds and don’t stick your head above the parapet (to name a few). Autonomy and individualism are prioritised in Western society so it is not surprising that we have mental health system that via a complex system of reattribution ultimately displaces the angst back to the person labelled with mental disease. 




The current approach


What can we salvage from the existing model of mental disease? Is it necessary or even possible to promote a paradigm shift from a concept that is so deeply engrained in modern society and serves many people well? And to what? Such paradigm shifts tend to occur at times of war, revolution or natural disaster. A Royal Commission is surely not comparable to such catastrophic events.  For now, let us assume that society changes along evolutionary principles. They are within the control of external forces (politics, social media, etc.) and Rumsfeld’s “unknown unknowns” and are not within the influence of Royal Commissions!


Returning to the metaphor of “wallpapering over cracks”, I opine that this is a reasonable and pragmatic approach. It also has the potential to be a sophisticated endeavour that could harness technology, resources and social buy-in. We (consumers and those working within mental health services) should make it abundantly clear that we are in the business of wallpapering over cracks (both societally and individually) rather than retreating to the paradigm of treating or preventing mental disease. 


On a systems-level we could acknowledge that mental health services attempt to wallpaper over social inequity. It is no coincidence that the majority of our consumers come from lower socioeconomic and educational strata in society. With the mental disease model, we are communicating “I know life is unfair…here is some support and treatment for your mental disease…now accept your place in society, shoehorn yourself in to a niche or catch up with your mentally normal peers”. The truth is that many consumers are so socially, financially and educationally disadvantaged that they find it nigh on impossible to catch up with or fit in to mainstream society. The wallpapering over the cracks metaphor has qualities of honesty and humility which are sorely missing in the mental disease model.


In every clinical setting that I have worked, the lowest common denominator or substrate of the work is an outpouring of emotion, distress and suffering. Even in persistent states of mind termed “psychosis” and “mania”, it becomes apparent that these are seemingly innovative, often unconscious manoeuvres performed by the psyche to split off, flip or disguise intolerable emotions and avoid reality. Those with so called “gross brain disease” (dementia, head injuries, etc.) are also trying to communicate their needs albeit through a distorted lens. Mental health professionals often prefer working with such patients – those who seem to disguise their suffering. It is a special type of expression of suffering, one that often defers overt expression of anger or aggression. When these behaviours do occur, it can be attributed to mental disease as opposed to being deliberate anger directed toward an object or self. This exemplifies the mental disease model in action - serving all parties well except perhaps the patient who has to accept being sick and may be the recipient of coercion and enforced treatment. These phenomena feed service model design facilitating preferential access and treatment to those who present their distress in specific forms.


What psychiatry terms “symptoms” are usually forms of communication and are often synonymous with suffering or distress. They allow people to convey the uncommunicable and if received appropriately by a recipient, facilitate the discharge of emotion. The dynamic of compassionate listening or even the giving of soothing medication that I observe between patients and nurses on a daily basis is just one example of this interplay. Just as I am discharging my angst by opining in this piece, patients often try to express and discharge feelings via expression of “symptoms” or behaviours. This process does not always follow the idealised, harmonious catharsis outlined in the nurse/patient example above.  We often see discharge of anger toward the self and others within relationships and families (what is now termed “family violence”). Interestingly, society is very clear that family violence, paedophilia and drug use are “bad” and possibly “evil” hence there is little appetite for bundling these social phenomena within the mental disease model.


Expressed or elicited opinions (regardless of whether they are labelled delusions, overvalued ideas, hallucinations or cognitive distortions) are always associated with strong emotion. Their expression allows a discharge of emotion (both positive and negative). There are a variety of techniques, procedures and behavioural technologies that allow discharge of bad feeling into a therapeutic relationship without causing undue harm to the recipient. Sadly, these are rarely incorporated into service design, models of care or the built environment within mental health care settings. Most mental health personnel and teams are not trained or experienced in these principles. They are often overworked or exist within high pressure environments hence they often go about their day internalising other people’s trauma contributing to burnout. 


As an example, expression of a belief that one’s soul is controlled by the movements of the moon may cause an emotion of amazement, wonder and disbelief in the other. The belief that all Jewish people should be shot because they are attempting to take over the world may evoke disgust and fear. My point is that similar phenomenology elicits very different responses in the recipient depending on the content. Emotion is also transmitted between mental health workers. As another example, a senior colleague with whom I worked shortly after arriving in Australia found it impossible to fathom why someone would choose to be homeless. He opined that such a decision was a symptom of mental illness (specifically of schizophrenia). My opinion was that a rejection of living within this society sometimes made sense which I duly repressed. When I explored his opinion, it seemed that he genuinely believed that Australian society was kind and lenient (frequently quoting “the lucky country” adage) hence rejection of it seemed pathological. His assertion evoked anger within me which was directed against him (albeit in a passive aggressive manner). I subsequently resolved this conflict by making hypotheses around the subtext. I was a recent arrival in a country that I deemed hostile to foreigners and he was an established psychiatrist who had never left the hospital at which he worked. Of course, many of my assumptions about him were probably erroneous but the point is that our opinions around homelessness were polarised by our underlying beliefs and the interpersonal dynamics between us.


When I work with people and form a so-called “therapeutic relationship” with them, it never ceases to amaze what emerges as the relationship unfolds. Whilst feelings of incredulity, joy and optimism occur within me I also experience boredom, disgust and contempt. I am aware that my patients also experience positive and negative feelings toward me. Conceptualising the other as having a mental disease constrains and restricts the range of feelings within this dynamic. I watch people’s beliefs about themselves, others and the world change over time. This appears to be associated with the relationship, containing overwhelming feelings with words and medication and developing trust but it is also due to the innate process of personal development and external “events” in the person’s life. On a metaphorical level, my doctorial role involves letting out pressure, shoring up and suturing of the psyche and has much more in common with the processes of surgery than medicine.


People seek out containment and help in unconventional ways. Over time, I observe people’s identity becoming subsumed by their illness. It can be one of the only means that a person has to access what they need. Over time, they may acquiesce to the idea of mental disease or disengage from mental health services altogether. If certain patterns, manifestations or forms of distress are preferentially rewarded in health and social care systems then it is not surprising that these behaviours persist and are preferentially expressed. It also follows that they may become engrained within a person’s repertoire of thought and behaviour. Those who express other forms of distress often go elsewhere to get their needs met e.g. toward self-medication with drugs/alcohol, presenting physical symptoms or self-harm. The number of presentations to medical settings with so called “medically unexplained symptoms” is not formally counted in this country nor are the number of restraints in emergency departments and other medical settings. Hidden statistics such as these may provide a proxy for the number of people presenting with distress in unconventional ways.  





Suggestions for the future


The mental health system is crying out for an alternative unitary model for thinking about mental health. One that incorporates human suffering, distress and symptoms. The advent of the recovery model and rise of the consumer movement is widely seen as a rejection of the prevailing mental disease model. The Royal Commission should encourage and collate “bigger picture”, overarching concepts which will allow various factions within the mental health system to exist under a banner and create a vanguard. This could form the basis for reform and service redesign rather than relying on the piecemeal funding and a factional approach that has been the mainstay of the post-modern age. It is worth exploring the reasons why the recovery model has not served this purpose thus far. A public acknowledgement by government that mental disease emanates from and is exacerbated by societal injustice and trauma would be a huge step forward. If the Royal Commission intends to focus on prevention then social and societal changes should be strongly recommended. Abolishing private education, expanding social housing and introducing inheritance tax would be far more effective in closing the gap than funding more Headspace and early intervention teams.


The Royal Commission should acknowledge rather than overlooking the widespread use of drugs and alcohol in Victoria. Mention of drug and alcohol use (or disorders) is conspicuously absent in the terms of reference yet the use of these substances is one of, if not the main determinant of causation, course and outcomes in many people with mental ill health. A fact that cannot be ignored is that alcohol use is sanctioned and promoted by the state as a way of relaxing and unwinding yet the use of illicit drugs is vilified. Mental health services need to adopt a pragmatic and considered stance on drug and alcohol use. 


Mental health services need to acknowledge that expression of distress and requests for help often don’t come in the stereotyped form of an outstretched, begging hand and dutiful compliance with Parson’s sick role. Equally, such expressions and requests do not need to be met with healing hands or by provision of whatever people mean when they say “support”. Psychodynamic theory and other concepts from the field of psychology, neuroscience and the humanities may offer a better means of understanding individual and societal behaviour than the concept of mental disease promoted by psychiatry. The Royal Commission should look here as well as listening to a representative range of people with lived experience. Listening to experts is clearly important but needs to be considered alongside the moral, ethical and political tone of society. Building a mental health service which is a “castle in the sky” could encourage further segregation of and cynicism toward an already disenfranchised group. At a time when people are desperate for change, “motherhood and apple pie” concepts abound. Intervening early, curing mental disease and treating perpetrators of heinous crimes are of course worthy endeavours. But if counterarguments to these initiatives sound preposterous then the proposition may be flawed. 


As a psychiatrist who has worked internationally, I experience Victorian mental health system as excessively coercive and inflexible. The rates of community coercion are amongst the highest in the western world as are the rates of restrictive interventions. We must build a system that is appealing to people who use and work within it, one that they want to work in and return to at times of failing mental health. It is likely that the use of restrictive interventions and coercion would reduce if the system was built along these principles rather than on the relentless pursuit of preventing suicide, protecting society and treating mental disease. In my work in the private mental health system people generally enjoy coming to and are satisfied with what is on offer. The suggestion that this is because people who use the public system are “sicker” or somehow different (the implication usually being socioeconomically) smacks of snobbery and should be challenged. There will be a role in mental health services for coercion and temporary deprivation of liberty for the foreseeable future (i.e. when a person lacks capacity to make certain decisions) but the current system encourages these approaches as a first port of call for severely distressed consumers. Frontline workers are often placed in a position of brinkmanship where restrictive interventions are used pre-emptively because of a reciprocal climate of fear (i.e. staff fear patients and patients fear the system). People remember how they were treated and in an age of consumer recommendation, they are unlikely to return voluntarily if their prior experience was poor. Offering treatment choices to consumers is as important as investment in the infrastructure, personnel and systems that underpin the service.


Medicine has a great deal to offer the field of mental health particularly to those individuals where suffering and behaviours have become engrained, persistent or subsumed one’s identity. It is the systematic, rigorous approach, inherent compassion, governance and safety offered by healthcare systems as well as the scientific method for finding new and innovative approaches which are beneficial and not the concept of mental disease. Actuarial-based assessments to predict the risk of suicide or harm to others are largely ineffective as is diagnostic classification. The surgical model involving consistently applied, localised, procedural and process driven approaches may have more to offer than the a systemic one. Technologies exist that can change persistent behaviours and thinking patterns but they are rarely offered in a personalised, proportional or co-ordinated manner to the most persistently distressed or behaviourally disturbed individuals. They take time, training and can be costly but the costs are often less than the unit cost attributed to treatment of some “physical” disorders. These are uncomfortable comparisons to draw but reinforce the need for non-negotiable parity between mental and physical health when it comes to expenditure. 


We need to devise more sophisticated and ethically informed approaches to human suffering. Whole population services that ladle-out care, support and advice to all comers may do more harm than good (both to society and to those who work within these services). The rapid expansion of youth mental health may well be creating cases of mental disease which would otherwise abate. The principle of proportionality should be rigorously applied within mental health services. Let’s provide support when and where a person needs it and move away from the principles of whole of population services. It is, in part the responsibility of a community and families to support people who are suffering. Public policy should not convey the message that this can be delegated to mental health services and NGOs. 


We should devise high quality generalised, transferable and replicable approaches to mental distress and dysfunction that can be consistently applied in every area mental health service in the state. This would still allow consumers to add-on components that they find helpful in addition to the core approach provided by the service. Specialisation, so-called “capacity building” approaches and centres of excellence have not achieved better outcomes in Victoria and it is time to focus on generalist approaches underpinned by theoretical frameworks delivered by well-resourced teams. Teams should be equipped to work with all ages and the range of presentations and not just those who present with classical forms of mental disease. Those with learning disability, chronic physical symptoms and cognitive impairment are too often overlooked and should be included within models of care delivered by mental health services. We need to focus on getting the basic elements of mental health care right. These include judicious assessment, development of a shared understanding of a person’s problems with living and development of therapeutic relationships. These elements may sound nebulous but they are sophisticated, intensive and systematised processes that require highly trained and supported staff. 


Clinical approaches comprising shorter term medication use, psychotherapies and care planning systems should be delivered with precision and fidelity. Powerful approaches such as coercion, restrictive intervention and so-called maintenance medications should be used proportionally. Honest explanation of the rationale for using of these approaches is preferable to hiding behind the concept of mental disease. Such honesty lays the foundation for a discussion between human beings rather than a deferential one involving a sick person and their healers. Something that I am able to assert with relative confidence midway through my career is that a great deal of human behaviour is predictable when you have a relationship with them. Instilling these approaches requires the continuous training and fidelity to standard practice seen in other medical and surgical settings.


In conclusion, mental health is better in the healthcare sector than existing elsewhere in the social care sector. However, if we’re in, we need parity with other parts of the healthcare system. Mental disease is a powerful metaphor which for all its faults allows us to exist within the prevailing model of the healthcare sector. However, it is not serving our consumers well. I feel privileged to work in a service where everyone I encounter (consumers and carers included) is committed to developing the world class mental health services that all Victorians deserve. Equally, I am saddened to see such a committed workforce struggling to deliver due to a chronic underfunding and neglect particularly when potential exists for us achieve outcomes for individuals and society. Rather than throw the baby out with the bath water, the Royal Commission should encourage a re-think of the substrates, systems and values that underpin delivery of mental health services across Victoria. The metaphor of wallpapering over cracks is humble but it is also pragmatic, realistic and honest and embraces the complexity of the task that lies ahead.