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.