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Epilogue
The Mental Health Reform Cakewalk: Moving Forwards Backwards
Daphne Habibis
School of Sociology and Social Work, University of Tasmania, Launceston, TAS
Abstract
This epilogue reviews the papers presented in this volume, drawing out the main themes and placing them in the context of the issues identified in the Not for Service report published by the Mental Health Council of Australia and the Brain and Mind Research Institute (2005). It uses the analogy of the cakewalk to describe the progress of mental health reform and the way in which progressive policies have been undermined over the reform period. It identifies the neo-liberal policy context, inadequate resourcing and workplace issues as critical contributors to this process. It concludes with an analysis of some of the key areas in which a sociological perspective can make a major contribution.
Keywords
mental health, mental health policy, deinstitutionalisation, neo-liberalism, risk, sociology
Article Text
The production of this special issue of Health Sociology Review is timely, coinciding as it does with the release of Not for Service: Experiences of Injustice and Despair in Mental Health Care in Australia (Mental Health Council of Australia and the Brain and Mind Research Institute 2005). Together the two documents provide a powerful analysis of some of the issues confronting people with mental illness and those who care for them. The sense of déjà vu experienced by any informed reader in response to the catalogue of serious inadequacies of service described in these two documents is as predictable as it is disturbing.
Once again, the question of why, despite a prolonged period of concerted efforts of reform, are the lives of individuals experiencing mental illness largely unchanged?
The papers presented in this volume represent an excellent sample of the rich insights that sociological analysis can provide in relation to this and other questions.
Writing in the 1970s, Juliet Mitchell8 described progress on women's equality as a cakewalk (1971). She was not using the term in the way it is currently used to refer to something that is a 'piece of cake' or a 'walkover'. She used it in the opposite sense but one which is more faithful to its original reference point - the dance African American slaves performed once a year in the homes of the white plantation owners. This dance, a combination of traditional African shuffle dance and a mocking imitation of the mannerisms of white slave owners, involved complicated and exaggerated steps - one step forward, two steps back - and it was in this sense that Mitchell used it to describe the progress of the women's movement. It expressed the frustration of feminists that, for all their efforts and apparent success, the fundamental inequities of women's estate remained largely unchanged. The papers in this volume convey a similar sense of frustration. It is evident in Pauline Savy's review of the history of deinstutionalisation, and of the current issues in the field of mental health and illness and in Clare Hocking, Janet Phare and Jan Wilson's account of the emptiness of the lives of formerly institutionalised men and women. For Janice Chester, deinstitutionalisation is an 'unrealised desire' and community treatment is simply 'fragmented parts of the psychiatric hospital that have spun off into smaller, but still institutionalised settings'.
The cakewalk analogy can be further extended. The dance represented a contradictory moment in relations between the black slaves and the white landowners. What was for one an act of resistance - the ridicule of white manners - was for the other the appropriation of potential subversion - it was enacted on the white man's terms. What appeared an emancipatory act was merely illusion. Today we have excellent mental health policies but they mask the reality of sub-standard services, serious unmet need and abuses of human rights. Many of the papers describe how enlightened policies have been subverted. Mike Hazelton's audit of citizenship and human rights in Australia contrasts the construction of people with mental health needs as consumers with the reality of their disempowerment. The promise of liberation has been overwhelmed by the increased use of 'seclusion', compulsory orders, imprisonment, homelessness and continuing marginalisation. Anne-Maree Sawyer analyses the changing climate of service provision from one focused on therapeutic treatment to one where risk management is the over-riding concern. Her findings are echoed in Julie Henderson's discourse analysis which documents the policy shift from an emancipatory, consumer focus to one which makes families responsible for care. She observes that 'care in the community has become care by the community'.
Yet it cannot be claimed that subversion of the policy goals was ever an intended outcome. Valerie Gerrand's analysis of mental health reform in Victoria is an optimistic account of how quickly effective policies can implement substantial change to services. Victoria remains the exemplary model for the other states and territories. It is 'the state that has undertaken the most systematic reforms consistent with the spirit' of the National Mental Health Strategy (Mental Health Council of Australia and the Brain and Mind Research Institute 2005:62).
These reforms represent significant progress. They include shifting the locus of care to the community, developing a whole-of-government social policy framework for mental health care, supporting the NGO sector in provision of recovery services and amending legislation for the protection of the rights of voluntary patients. Yet the problems remain.
The Not for Service report highlights the following as the areas of greatest concern in Victoria:
- ongoing problems of access to acute and emergency care, including inadequate provision of acute care beds and medium term services
- patchy services, especially in rural and regional areas, including the mal-distribution of all health staff who are concentrated in capital cities
- a continued imbalance between acute and community services;
- a limited focus on early intervention
- continued failure to achieve core human rights goals of social, economic and political participation of people with mental illness
- lack of accountability for mental health spending, service deficits and critical incidents
(Mental Health Council of Australia and the Brain and Mind Research Institute 2005:62).
A 2003-4 surey conducted by the Victorian government into consumer and carer experience of Victorian public adult mental health services revealed levels of dissatisfaction (i.e., negative responses) which, for key indicators, ranged from 28-42% for consumers and 42-55% for carers (cited in Mental Health Council of Australia and the Brain and Mind Research Institute 2005:63). Similarly, high levels of dissatisfaction were also evident in the public forums, submissions and consultations collected for the Not for Service report.
Some answers to this gap between admirable and progressive policies and the sense of failure and crisis that prevails at the coalface are provided in this volume. One contributory factor is the role of the media in constructing public discourse about the state of mental health services and the potential dangers of failed reforms. Whilst the media can act as an advocate for people with mental health needs, Sawyer's paper documents the way adverse reports of the 'failures of deinstitutionalisation' and its associated 'tragic consequences' have fuelled retrograde policies in Victoria. She argues that the goal displacement that took place in Victoria in the 1990s in which risk management replaced therapeutic care as the central service objective was directly linked to media coverage of critical incidents. The nature of this sort of coverage is documented in an Appendix to the Not for Service report. This lists the headlines used in the articles describing mental health care issues in fourteen national and capital city papers in the 22 months between August 2003 and May 2005 (Mental Health Council of Australia and the Brain and Mind Research Institute 2005:1000-1003). Words such as 'suicide', 'blame', 'risk', 'tragic', 'inquiry', 'failure', 'death' and 'jail' are repeated with depressing frequency.
The contributions to this volume identify the domination of neo-liberalism in social policy as critical to the failures of the system. Henderson's discourse analysis of key state and Federal National Mental Health Strategy documents between 1988 and 2004 traces the consumer and carer movement's demise from an emancipatory movement in the 1970s to its current form in which consumers are constructed as individuals, responsible for their own health through the expectation that they make 'sensible choices'. A key goal of the carer movement was to challenge policies which stigmatised families and excluded them from constructive engagement with state provision of care. It aimed to establish a new relationship based on mutual respect and recognition of expertise. Instead, treatment services today use families as a resource, whilst simultaneously permitting declining levels of consultation on the planning and delivery of mental health services.
Sawyer locates the ascendancy of risk management in Victorian Crisis Assessment Teams in the context of the new public management that accompanies the neo-liberal agenda. She describes the obsession with documentation that has come to replace care. The quantitative measurement of performance, the concern with targets, inputs, outcomes and indicators, has transformed the clinician into an administrator and has created a demoralised and dehumanised workplace. The audits and reviews require the right boxes to be ticked whilst at the same time practitioners and consumers experience service decline. Clinicians then face the task of reconciling the contradictions between, on the one hand, policy rhetoric and, on the other, the bureaucratic requirements of risk assessment, risk management and avoidance of litigation, on the other.
The question of funding is clearly central to any explanation of success or failure of the deinstitutionalisation project. Gerrand points to the siphoning of the savings from the closure of the asylums into general revenue rather than into community based services as fundamental to the failure of deinstitutionalisation in so many service settings, both within Australia and overseas. She explains much of Victoria's early success and later failure to the same source. The initial determination to preserve the funds saved from closing the asylums for community treatment and staff training was eventually eroded. The direct consequence was a deterioration in these and other areas of service.
The Not for Service report identifies inadequacy of funding as a national issue. Whilst total expenditure on health care has risen dramatically, funding for mental health care has remained static at less than seven per cent of recurrent funding. This is despite the fact that the burden of care associated with mental health and illness is over 13 per cent (Mental Health Council of Australia and the Brain and Mind Research Institute 2005: 36, 47). An increase in recurrent funding relative to the burden of disease is a key recommendation of the report. It is not possible to take seriously the language of inclusion and human rights that dominates the policy discourse if it is not matched by the required level of resources.
Workplace issues are also critical to policy implementation. Continuing rigid disciplinary boundaries within the mental health professions are a major impediment to the development of innovative service models and the advance of new knowledge. Gerrand describes how conflicts between psychiatrists operating within the medical model and the more social models of interdisciplinary allied health teams are an impediment to reform.
The cakewalk analogy, whilst useful, fails to capture the full complexities of the effects of deinstitutionalisation. Deinstitutionalisation may have failed in some respects but there have also been successes. One important difference is identified by Katy Richmond and Pauline Savy. People with mental health needs are now definitely 'in sight and in mind'. Whilst excellent policies may not be realised in practice, they nonetheless represent a solid foundation for change. The depressing succession of reports documenting the perennial state of crisis in mental health care has, at least, cast the public gaze firmly on the key issues and this will, over time, keep up the pressure on governments. Whilst the level of concern may not be sufficient to create the political compulsion necessary to effect the radical changes required, the issues are on the agenda. This agenda is now also firmly tied to that of human rights in which the vulnerability of people with mental health needs is understood.
The debate on deinstitutionalisation has also shifted. While public discourse may trumpet that deinstitutionalisation has failed, no one is seriously suggesting that we should return to the asylums. Treatment in the community remains the desired policy goal. The expense of the asylums, the potential for abuse behind closed doors and the inevitable stigmatisation are too well understood.
Deinstitutionalisation may be unfinished business, but the critical question is not 'should we return to the asylums?' but 'how can we make community treatment work?'
The need to move the debate forward is the central argument presented by Janice Chesters. Her research into the history of mental health reform challenges many of the liberal assumptions about the benefits of community treatment and points to the cyclical nature of the community versus institutional care debate. She argues that not only is the debate not new but it also misses the point. It is not the locus of care that matters, but its quality. Whilst inadequate services may be more visible in the community, we now know that location affords little protection against systemic neglect. She observes that 'community treatment does not equal humane service'. It is time to stop blaming service failings on the locus of care and instead focus on quality, funding and commitment.
This special issue of Health Sociology Review has been produced in order to foreground the potential contribution that sociologists can make to current debates about mental health reform. A number of the papers note the relative silence of Australian sociologists in this field. The reasons for this silence are debatable but one may be that, as a field of study, the sociology of mental health and illness lacks a clearly identified home, making it an uncomfortable space for sociologists to work within. It belongs broadly within the field of health sociology yet health sociologists ignore it. Because so few people work in the field the practice of those who do can be rather lonely. Perhaps this is, in itself, a reflection of the marginal, and in some areas, even stigmatised, status of mental health within health care generally.
A related reason may be the difficulty of attracting research funding. Mental health research has been the Cinderella of health research so that even clinical research dollars are scarce (Jorm et al. 2001)6. This makes it especially hard for sociological projects to attract funding since they may not make an accepted contribution to the evidence base or fit the medical model, especially if they use qualitative methodologies. Furthermore, some topics slip between the funding criteria of the National Mental Health Research Council and those of the Australian Research Council.
The silence is also two-sided. The potential of sociology to contribute to mental health and illness debates is poorly recognised within the field. For a field that is acknowledged to be interdisciplinary there is insufficient recognition of sociology's place as a key contributor. This gap is illustrated by a key text on mental health in Australia (Meadows and Singh 2001)7 which is seriously sociologically challenged. The book is aimed at clinical mental health workers and, as well as focusing on clinical practice, aims to set out the context of mental health in Australia and the contribution of the various disciplines. Yet it contains only one page on the sociology of mental illness. Of the forty nine contributors, Yoland Wadsworth is the sole sociological representative in her discussion of action research. Whilst there are major sections on consumer perspectives, apart from a discussion of stigma and discrimination, major social issues which impact on the daily life of clinicians - such as the policy context of clinical governance or the complex relationship between need and service provision - are neither identified nor examined. The voice of sociologists at conferences is similarly limited. Despite widespread acknowledgement of the social nature of mental illness this does not translate into active engagement with, and encouragement of, the rich insights afforded by a sociological perspective.
One explanation for this myopia may be the historical association between sociology and radical psychiatry and its continuing challenge to the biomedical model. Another is that the voice of sociology has been subsumed by the voice of consumers, a pattern common to the field of health sociology in general. Whilst the inclusion of consumers is a key goal of many sociologists of mental health and illness it seems that in the crowded house of health some rooms are bigger than others and the one available to the social is rather small. In this sense, the limited voice of sociology needs to be placed in the context of the reluctance of other disciplines to provide it with the necessary space.
The largest room in the house is clearly that of psychiatry, and clinical research dominates the field. However, a systematic review of research priorities noted the different views held by diverse stakeholders (Jorm et al. 2001). One striking finding was that the two research groups that have most influence on what research gets funded (the NHMRC panel and the Rotary Committee) stress quite different areas from those identified by the consumers and carers who ultimately benefit from the research. The research funding groups emphasise 'the involvement of science' whilst consumer and carer advocates emphasise 'the involvement of consumers in planning the research' (Jorm et al. 2001:80). This translates into different priorities for research topics, for example, risk factors versus service evaluation and training of health professionals. This suggests that one way of expanding the space for sociologists is to link their research agenda to that of those most affected by it.
One obvious area for such a commonality of interests is in the examination of workplace issues and their nexus with social policy. One area of crucial concern is the new managerialism which, it is argued here, carries significant responsibility for the subversion of mental health reform. Other critical issues include training, the negative cultures within mental health services, conflicts over professional boundaries and hierarchies, the challenges practitioners experience in meeting competing demands, how to attract and retain appropriately qualified and skilled staff to rural and regional areas and the relationship between the public and private sectors of mental health care. Sociological concepts such as risk, trust, medical dominance, discourse, governmentality and community offer powerful tools for understanding the nexus between policy and practice.
Another important arena is to assist service users to achieve deeper appreciation within the community of the subjective experience of mental illness. Despite its obvious importance and the rise of interpretivist perspectives and methodologies, this remains largely untravelled terrain. The work of Strauss (1989)13 and Estroff3 (1989) on identity construction and mental illness is most influential in this field. Corin2 (1990) draws on Ricoeur and Strauss to offer a phenomenological exploration of how individuals recovering from schizophrenia stay out of hospital. She concludes that their degree of success is closely related to particular ways of 'being in the world'. Her emic approach to understanding recovery makes sense of behaviours that are otherwise open to misinterpretation. She argues for new ways of interpreting the social withdrawal that is sometimes associated with a diagnosis of schizophrenia. She develops the concept of 'positive withdrawal' to describe the way some of her respondents found a way of 'being in the world' that enabled them to stay out of hospital. She is one of a small group of researchers, many of whom are working within the 'psy' disciplines, who are developing this field overseas. In Australia, Savy (2004) uses a similarly sensitive, phenomenological approach to give voice to the otherwise closed and silent worlds of Alzheimer sufferers
Such studies are invaluable for many reasons. They open the door to the 'being for the other' identified by Bauman1 as the core feature of morality in late modernity (1993). They provide powerful insight into experiences that are central to understanding of processes of treatment and recovery. They shed light on 'the management of the self' in response to experiences and processes such as trauma, dependence, support, discrimination and stigma. Through the sympathetic portrayal of the inner worlds of people experiencing mental health difficulties they enhance the capacity for their effective engagement with mental health workers, and for improved social relations in general.
More broadly, a number of authors in this volume have identified a need for research into the everyday experiences of users of mental health services, and by extension, of the services themselves. Qualitative studies of acute care wards would provide much needed understanding of the aetiology, maintenance and effects of the 'toxic cultures' that can develop in mental health services (Mental Health Council of Australia and the Brain and Mind Research Institute 2005:487). They would be invaluable in exploring how departments of emergency medicine make triage and referral decisions relating to mental illness in the context of narrowing definitions of need. They also shed light on whether and how carers' lives are affected by policy changes.
Service evaluation has been identified as a field of particular interest to users of mental health services. Richmond and Savy in this volume write of the need to explore different forms of service delivery, from mobile support teams, to innovative models such as psychiatric telephone triage systems. Supported housing is critical to both recovery and maintenance of mental health. Whilst there has been significant work in this area (Reynolds, Inglis and O'Brien 2002; Robinson 2003)9, 10 there remains a need to evaluate specific models. There are also significant opportunities for case studies and action research on what forms of medium and long-term care work best in specific communities in order to identify best practice. Evaluation of acute care wards is also long overdue (Habibis et al. 2002)5.
Beyond these areas are many others of importance. The broad area of the relationship between mental illness, inequality and marginalisation remains under-researched. The debate about the relationship between mental illness and class remains open with an ongoing need for longitudinal, population-based studies (Pilgrim and Rogers 2003:24). Whilst such research is unlikely to be funded within Australia there remain many other opportunities for helpful contributions. The lack of basic data on issues such as employment and access to welfare has been identified as a critical gap in our knowledge. Whilst the fact of the criminalisation of mental illness is well understood, research in Australia has been minimal. There is a need for a research agenda using quantitative and qualitative methodologies to identify rates, patterns, experiences and effects of custodial care. Research into pathways from mental illness into prison and of the critical role played by the police is one important area. Ethnographic studies exploring constructions of deviance versus sickness within the justice system is another. Documentary analyses of files, policy documents and media reports on how discourses of 'danger', 'risk' and 'need' are constructed within the community and by key professionals offer a largely untapped research resource. Sociologists of mental health could also add to the body of knowledge about asylum seekers that sections of psychiatry and social work have begun to develop, focusing especially on human rights abuses.
More broadly, there is a need to locate constructions of mental health and illness, and social policy responses, within the context of modernity. Sawyer identifies some relevant areas in her reference to debates about individualisation (e.g., Sennett 1998)12 detraditionalisation (Giddens 1990; 1991)4 and its effects on social support and new forms of self-governance (Rose 1998)11. She raises the interesting question of whether there are 'new forms of psychic and emotional distress culturally and historically specific to late modernity'. Such themes could be usefully applied to topical issues such as the relationship between cannabis use and psychosis.
This pot-pourri of potential areas requiring investigation in no way comprises a systematic review of the field. There are many other important areas worthy of mention including gender, cross-cultural and rural issues, the role of the pharmaceutical industry in treatment and the effects of welfare and industrial relations reforms on the lives of consumers and carers. They are, nonetheless, indicative of the sorts of contribution sociologists can make. Sociology's core business of casting a critical eye on the nexus between culture and the self, between policy and practice, between organisational arrangements and individual biographies is essential for the field. Its freedom from rigid frameworks and its ability to combine the insights of other disciplines, especially philosophy, give it a capacity to move beyond the confines of disciplinary boundaries which is especially valuable to the area of mental health.
This volume demonstrates the excellent work that sociologists can do in contributing to public debate and keeping the issue of mental health and illness on the political agenda. One encouraging step is the formation of a TASA (the Australian Sociological Association) thematic group in the area of the sociology of mental health. A collection of sociologists working in the field, including many of the contributors to this volume, has recently been formed. Convened by Katy Richmond and Pauline Savy, the group will hold its inaugural meeting in Melbourne in February 2006. All readers of Health Sociology Review are welcome to attend this meeting.
Acknowledgements
I would like to acknowledge and thank Robert Bland, Pauline Savy and Karen Willis for their helpful advice in relation to this paper.
References
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