IAN WEBSTER. Policy failures in mental health

Mental health problems arising out of modern despair have to be tackled with insights gained from the day-to-day lives of society’s outcasts and the social sciences.  Matthew Fisher, (Australia’s policy failure on mental health, Pearls and Irritations, 14 December 2017) argues that Australian mental health policies have failed: “(We) are subject to a deafening silence from politicians, organisations and the key individuals who shape Australia’s policy discourse and action on mental health”. The ubiquitous mental health problems arising out of social conditions and chronically stressed lives are neglected: “The social causes of mental illness and their impacts on populations, as something we might act on, are largely hidden”. 

Australian mental health policy is dominated by the need to provide treatment – psychological and medical – for individuals suffering a mental breakdown. Drugs, cognitive behavioural and other forms of psychotherapy can help with some defined syndromes but they cannot touch the burgeoning social anxiety and insecurities affecting modern populations. That one in five people experience a mental health problem in 12 months shows the magnitude of the mismatch. The continuing demand for increased funding for mental health services and the widening definitions and ambiguities of mental health, create a vicious circle of symptoms and demand for treatment.

From when the first National Mental Health Plan was agreed in the 1990s, mental health policy has been under a barrage of criticism. Dissatisfaction has come from those affected – individuals, families and frontline responders – and strident and confected criticism has come from a range of mental health groups and advocates who could see benefit if their views and services could get traction and a national foothold.

Unfortunately, the mental health sector, so vitally important to our society, is riven by competing interests and paradigms. There is competition for influence and funds, and deeply felt contests over volition and coercive treatment and the framing of mental illness and its treatment.

When in late 2011 the Gillard Government signalled its intention to set up a National Mental Health Commission (NMHC), there was hope for an upbeat national approach to mental health and reconciliation of some of the competing interests.  In 2012 the NMHC was given the brief to provide an annual ‘report card’ directly to the Prime Minister on Australia’s mental health. How then should a ‘report card’ be framed? The usual approach of calling for submissions from organisations and mental health professionals would simply regurgitate the existing dissatisfactions and arrangements.

The answer came from a Commissioner representing people with mental illnesses, Ms Janet Meagher, someone who not only understood the impact of mental illness on daily life, but knew of how the rights of disabled people were so often violated. The issue, she said, was to focus on discrimination and the report card should be shaped by the basic rights of people living with disabilities – to education, justice, accommodation, employment and participation in community life. The Government had already adopted the United Nations Convention on the Rights of Persons with Disabilities in 2008 which, translated into mental health, means the ability of people with mental health problems to lead a contributing life; a right for everyone. The ability to lead a contributing life thus became the central principle for the NMHC in 2012 and 2013.

There were two other important ideas. Recovery is not to be equated with medical or rehabilitation outcomes, as defined by others, but to be seen as the individual achieving a contributing life within their capabilities and on their terms. The second is to appreciate the contribution of the mental health consumer movement, that is, to listen and respond to the aspirations and needs of those with mental health problems.

During this period the NMHC was informed by extensive engagement with mental health consumers and with Aboriginal and Torres Strait Islander communities. The Commission’s priorities became to maintain and improve physical health, relationships and connectedness, education and employment, safety and justice, support and care, as well as to prevent suicide. Mental health policy was to go beyond individualised treatment paradigms and be open to social relationships and causes.

In September 2013, the Abbott Government replaced the Gillard Government. The new Government appointed a Commission of Audit to review the efficiency and effectiveness of government programs and to reduce duplication. And the NMHC was to report to Mr Peter Dutton, the new Minister for Health, and not to the Prime Minister. Dutton’s body language and lack of engagement showed his discomfort with the Commission’s work. He directed a complete change in direction. The NMHC was to report on the efficiency and effectiveness of mental health programs and services with suicide prevention as an add-on. The auguries were not good for a social/public health view of mental health.

The NMHC continued, but the blush of excitement for a wider social perspective was lost. The focus shifted to service provision, costs and individualised treatments, important as these may be for those affected.

Mental health has struggled on other occasions to frame a population approach –  for example, in the early 2000s this was the mission of NSW Centre for Mental Health, but the Centre was disbanded. Media reports of crisis events in mental health services and the supposed mental illnesses in high-profile acts of violence, have repeatedly dragged socially constructed mental health policies back to illness and containment.

Mental health problems arising out of modern despair have to be tackled with insights gained from the day-to-day lives of society’s outcasts and the social sciences. Such was the vision in the early 2000s which led to the setting up of mental health commissions.  As Alan Rosen, NSW Mental Health Commissioner and Drs. Goldbloom and McGeorge said in 2010, “[mental health commissions] can encourage, champion and monitor the transformation of services into more evidence-based, community-centred, recovery- oriented, consumer, family and human rights-focused mental health services” (Current Opinion in Psychiatry, 2010).

These aspirations foundered with the appointment of Dutton to the Health portfolio in 2013, as mental health policy then regressed to rationalisation of existing services. Let’s hope the future discourse in mental health can regain a focus on social causes.

First, the over-all well-being of the population should be a policy issue separate from policies to provide needed mental health services.

Secondly, if the well-being of the population is our concern, we must be concerned with the conditions of the population. The despair arising out of social conditions is manifest in – mental disorders, alcohol and drug problems, addictions, problems of obesity, suicide and unresolved suffering. Their social determinants reach well beyond departments of health and up-scaled mental health services, and demand social and structural responses. Policies relevant to mental health should, therefore, be embedded in all government departments, especially human service departments, and coordinated at the highest level through committees of cabinet.

Thirdly, the National Mental Health Commission should report directly to the Prime Minister, as it once did, and state and territory mental health commissions should report directly to Premiers and Chief Ministers respectively.

Fourthly, mental health should be a central plank in the direction and advocacy of non-government public health and social welfare organisations, such as the Australian Public Health Association and the Australian Council of Social Services, and their state and territory counterparts, alongside the advocacy role of the Mental Health Council of Australia and its state and territory counterparts.

Ian Webster is Emeritus Professor of Public Health and Community Medicine, University of New South Wales and was a National Mental Health Commissioner from 2012 to 2014.

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