Mental health - it’s time for a new paradigm

Maxine Drake, of the Health Consumers Council of Western Australia, is one of the bold new voices in mental health. “We are over government”, says Maxine. Self-help, peer-based supports and social enterprise, she says, are our pathways out of the dysfunction of fractured services, disconnected programs, chronic unemployment and social isolation.

Mental health is a fashionable topic for politicians and commentators, but the public debate remains firmly stuck in the old social policy paradigm - what should governments do? How much should public spending be increased? What new programs are needed?

Funded services and agencies have an interest in maintaining this focus in the debate. After all, when politicians declare their concern for mentally ill people and promise more support, what they mean is that more public funds will be channelled into programs delivered by funded services and agencies. It’s a cosy relationship of mutual dependence that is replicated throughout the whole of the human services.

Consumers and carers are then required to line up to receive these programs, dispensed in neat disciplinary boxes which reflect professional demarcations and departmental silos. What’s wrong with this?

What’s wrong is that this system of organising social responses for a community of needy people, like the mentally ill, is a flawed and ineffective system. It’s wrong because people live messy lives, which don’t fit neatly into the segmented programs of well-intentioned officials.

Social isolation remains the primary life condition for most people with mental illnesses. Recovery requires the formation of social relationships and integration into mainstream life, work and play. For this reason, de-institutionalisation was a necessary step towards social recovery at an individual level, and a more effective support system at a societal level.

In dispersing supports throughout the community, however, the locus for activity shifted from institutional settings to civil society - that is, to the relationships and voluntary associations people make through interacting with each other, outside formal arrangements, and in particular, outside processes controlled by governments. And at this point, the de-institutionalisation process broke down, for three reasons.

First, politicians, policy-makers and service-providers had barely given five minutes thought to how civil society relationships with people who are mentally ill would develop - in what settings, around what interests, with which people, and with what kind of nurturing and support?

Can such relationships develop spontaneously? Usually not, they require careful nurturing informed by experience and expertise. De-institutionalisation required development of the will and capacity of family members, shopkeepers, sports officials, bus drivers, and hotel proprietors to form and maintain relationships with people with mental illnesses. This is far from easy. It was never a headline-grabbing challenge or a vote-winning election policy.

For instance, when more than 80 per cent of people with a mental illness are unemployed, what kinds of enterprises, in what industries, what kinds of support, are going to employ them? Until very recently, almost no thought had been given to this question. Today, the Federal Government still finds it easier to re-shuffle recipients of the Disability Support Pension from one payment to another, rather than find enterprises that welcome people with a mental illness.

Second, peer-support among people with mental illnesses is critical to overcoming social isolation, and beginning the process of recovery. More than most members of the community, people with mental illnesses are in dire need of social capital (expressions of trust and reciprocity on which a life can be built), and this is always best developed in settings based on horizontal exchanges and peer-based networks.

Italy has a highly developed network of peer-support organisations run by and for people with mental illnesses (structured usually as co-operatives and run on enterprise models) which provide a wide range of supports, employment, housing and other activities.

Maxine Drake in Western Australia is leading the development of steps towards mutually structured, consumer-centred support models. Their first venture is a kind of mental health co-operative based on contributory principles where consumers pool resources to fund supports in emergency situations, designed by themselves with support people appointed by themselves. Enterprises tailored explicitly to employment of people with mental illnesses are also on their agenda.

Our service system lacks this kind of mutual entity, which should have been put in place as an accompaniment to de-institutionalisation. It wasn’t - because our service delivery tradition is provider-centred and oriented to dispensing supply-side provisions to “clients”. This tradition is still an obstacle to the development of advanced peer-support models.

The third reason why the de-institutionalisation process broke down was that the financial assets that flowed from the closure and sale of institutions were never transferred fully to resource community supports. The rigorous scrutiny that follows large-scale financial transactions in other parts of government was never applied here, which reflects, at least in part, the absence of a well-developed sense of “voice” for this community, with some commensurate political clout. The resourcing of community supports has never been adequate, and has never been focused strategically on relationship-forming activity of the kind that can generate peer and family-supported independent living.

Four insights remain critical to turning the public debate on mental health away from the old paradigm of managing  disadvantaged people by conscripting them into programs:

1. People with mental illness desperately require social capital (expressions of trust and reciprocity on which a life can be built) as a stepping stone to recovery. This requires mutual, peer-based forms of support and organisation around which wider supports and specialist interventions should be developed. We should not begin with the specialist interventions in the absence of mutual community-based supports - to do so is to repeat one of the critical mistakes of the past.
    
2. People with mental illness also need relationship-forming opportunities in civil society, which can only be achieved outside service delivery agencies of the “professional-client” type. Civil society associations like churches, service clubs, sporting clubs and arts groups are the most likely settings for these relationships.
    
3. Enterprises which actively want people with mental illnesses to work in them are needed, and there are a number of successful models emerging in Australia and overseas. The public policy priority in employment creation for people with mental illnesses should be on support for this kind of enterprise creation.
    
4. Brokered packages of direct funding for individuals who pool resources from several funding streams are our best antidote to the fracturing of the service system around service types and disciplines (psychiatric interventions, housing, social support, respite, employment and training) because it allows for enterprising uses of these funds which would otherwise be tied up in programs. Integrated financial packages should be payable to brokering entities chosen by people with mental illnesses and their carers, including brokering entities formed as mutuals of consumers.

Consumers and carers have been largely invisible in the public debate about mental health. We need to find a loud collective voice that is distinct from the service providers that can drive a new social and public policy consensus around these insights. We need a voice that is as influential in politics and government as that of large industry and trade union interests. The numbers are there for us to do it, what we need is leadership and organisation.