Since 1905 a number of approaches have been adopted to manage and provide treatment to problematic users of alcohol and other drugs in Western Australia (WA).
The term ‘treatment’ is used to loosely describe the broad conceptual approaches for managing problematic users that have operated in WA over the period. However, our contemporary understanding of the term ‘treatment’ is an inaccurate characterisation of punitive practices accepted in the earlier part of the period, even though described as ‘treatment’ in official accounts of that time.
In summary these approaches are referred to as –
- civil commitment model (1905 – 1975)
- public health model (1975 – mid 1990s)
- quasi-privatised market model (mid 1990s – present)
- sobering up centre model (1990 – present)
More detailed consideration is contained on the relevant page for each model.
Civil commitment model (1905 – 1975)
The civil commitment relied on provisions in inebriates legislation, coupled with mental health services operated ‘asylums’, to compel such persons to undertake detoxification and supervised rehabilitation.
This approach was not supplanted until the early 1970s, when the Alcohol and Drug Authority (ADA) was established, marking the development of a system of specialist treatment services in WA, completely separate from the mental health system.
Public health model (1975 – mid 1990s)
The public health model was designed to avoid the stigma associated with treatment within the mental health system, which had equated problematic use of alcohol with mental illness.
The public health model was implemented by the ADA and operated from 1975 to the mid 1990s. This approach involved the development of a limited number of places in a short-stay designated detoxification hospital setting augmented by a limited longer term rehabilitation programs and outpatient services to consolidate post-detoxification recovery.
Key features of the ADA service model included reliance on a single agency to establish and operate services, voluntary admission to all stages of treatment, expansion of outpatient-based services in both the metropolitan area and regional cities, early stage intervention as the primary mode of treatment, and support of community-level health campaigns to change attitudes and behaviours about alcohol and its use.
The ADA was an independent statutory body, in theory, even though it reported directly to the Minister for Health and all members of the Board were appointed by the Minister.
Sobering up centre model (1990 – present)
The rationale for establishing sobering up services, rather than medically supervised detoxification and treatment, stem from findings of the RCIADIC, that sobering up centres (SUCs) were a mechanism for police to convey intoxicated people to a safe place for overnight care, as an alternative of them being held in police lockups.
This approach to the management of intoxicated people was based on the concept of a low threshold for entry and whilst supported the development of low-cost multiple services in small communities, it may have precluded discussion of expanding the rationale of SUCs beyond their narrow ambit as originally determined in 1990.
Quasi-private market model (mid 1990s – present)
The development of a quasi-privatised market model for delivering services started in the mid 1990s. This model replaced the ADA public health model by the devolution of responsibility for delivery and management of direct services to a dispersed range of residential and non-residential programs operated by non-government organisations (NGOs).
Except for Next Step Specialist Drug and Alcohol Services (Next Step) detoxification hospital in East Perth, responsibility for former ADA-operated treatment services were transferred in November 1997 to NGO-operated Community Drug Service Teams (CDSTs), which were substantially, if not wholly reliant on public funding through managed contracts.
The impetus for creating a quasi-private market in treatment services arose from government’s embrace of principles of economic rationalism, based on efficiency and contracting out of services. One consequence of this reform was that direct service provision by government was limited to high cost programs, such as inpatient detoxification.
However, this model of contracting out was modified with respect to the two CDSTs established in the northern half of the State, as the contracts were awarded to the two already existing publicly operated regional health services.
In early 2003 DAO implemented an expanded model of funding area-based co-located treatment services, Community Alcohol and Drug Services (CADS), a feature of which was that the financial responsibility for establishing and overall management of each service was directly underwritten by DAO.
Also, at this time, the statutory shell of the ADA was transferred under a new administrative arrangement to the Drug and Alcohol Office, which had been established in July 2002. The creation of DAO also involved aggregation of the Mental Health and Public Health Divisions of the Department of Health, with the WA Drug Alcohol Strategy Office and Next Step.
The CADS arrangement involved co-location of NGO service providers and DAO-employed medical and other professional health providers in ‘a one-stop shop for clients in that both Next Step and a range of non-government and other providers including GPs are located together, providing a wide range of services, support and referral.’ The first such service was in the south metropolitan region catchment area, with three more CADS established in the rest of the metropolitan area by the end of 2007.
The final configuration of this arrangement is four metropolitan CADS, seven regional CADS, the Next Step service and a Drug and the Alcohol Youth Service in East Perth, adjoining Next Step, which was also run by a NGO.
In summary, by the late 1990s, the ADA had been absorbed into the DAO arrangement, which in addition to the Next Step detoxification facility in East Perth, undertook roles related to training and education, funding of direct treatment services provided by NGOs and oversight of large-scale community based public education programs concerned with alcohol and other drugs, except for Health Department’s retention of tobacco control programs.
As a result of the Alcohol and Drug Authority Amendment Act 2015, the statutory framework of the ADA was replaced by the Alcohol and Other Drugs Ministerial Body and the Alcohol and Other Drugs Advisory Board, under provisions in the Alcohol and Other Drugs Act 1974.
Future developments: Compulsory treatment
The McGowan Government announced in 2016 that it would investigate the feasibility for establishing a legislative framework to compel problematic users of alcohol and other drugs, in particular problematic users of amphetamine type stimulant (ATS) drugs, such as methamphetamines, to enter residential-based detoxification services and undertake rehabilitation.
An exposure draft of the Compulsory Treatment (Alcohol and Other Drugs) Bill 2016 was released for comment in September 2016 by the Mental Health Commission (MHC). A Community Advisory Group was announced on 27 February 2020 to further investigate this proposal.
This approach may indicate a return to a commitment model of treatment, possibly like the approach under the Convicted Inebriates Rehabilitation Act 1963, overseen by the Convicted Inebriates Board.
This arrangement was to operate a prison-based unit for the ‘treatment’ of problematic users of alcohol, until the closure of the Karnet Prison Inebriates Unit, after the opening of the ADA in November 1974.
A report in November 2019 of a WA Legislative Council Select Committee, which had investigated approaches for treating illicit drug users, did not support compulsory treatment at that time because of a perceived insufficient voluntary treatment services.
The Committee pointed out limitations that would exist in the use of the Mental Health Act 2014 (MHA), if that was to be used to commit a drug user to a mental health facility for treatment.
Although WA does not have compulsory alcohol and drug treatment, it does provide for the involuntary treatment of mentally ill patients. The MHA enables authorised staff to detain a person involuntarily for treatment, or examination in order to assess whether an involuntary treatment order (ITO) is appropriate.
The MHA provides for detention for up to 72 hours, or 144 hours in regional areas, for the purposes of assessing whether a person is suitable for an ITO. A psychiatrist can make an ITO when specific criteria is met, including that –
- the person has a mental illness that requires treatment
- there is significant risk to the person or another
- the person is not well enough to make decisions about treatment
- there is no less restrictive way of providing the person with treatment.
The MHA provides that a person does not have a mental illness simply because they use drugs, but has a mental illness if the person has a condition that –
- is characterised by a disturbance of thought, mood, volition, perception, orientation or memory
- significantly impairs (temporarily or permanently) the person’s judgement or behaviour.
The Committee heard from clinicians who agree that a person can be held under the MHA while they are experiencing psychotic symptoms, because they meet the criteria. Psychotic symptoms usually resolve within a day or so. People in this situation will often simply be held under hospital duty of care.
In that situation when someone is acutely intoxicated and having those symptoms and their judgement is impaired, they would more commonly be detained in hospital under the principle of duty of care to protect their safety until a period when they are no longer intoxicated and regain the capacity to make decisions about their welfare and discharge.