Mental Health Reform: Personal Responsibility & Social Justice


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Talk given at the RCN's International Conference for Psychiatric Nursing on mental health reform. The talk describes the ethical challenge facing nurses as government policy both undermines mental health and avoids the need for meaningful reform. Can nurses work with people to bring about the necessary changes?

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Mental Health Reform: Personal Responsibility & Social Justice

  1. 1. Personal Responsibility & Social Justice key elements in mental health reform Dr Simon Duffy ■ The Centre for Welfare Reform ■ 6th September 2013 ■ International Network for Psychiatric Nursing Research, RCN, University of Warwick
  2. 2. Dr Simon Duffy • Worked with disabled people for 24 years, invented personal budgets and developed self- directed support • Philosopher, with an interest in ethics and social justice, • NOT an expert in mental health.
  3. 3. The Centre for Welfare Reform • Welfare state is good - it is just designed wrong. • Move away from meritocratic thinking, instead value human diversity & equality • New thinking must promote justice, citizenship, family & community. • Innovate to build practical alternatives
  4. 4. 1. Questions of mental health cannot be separated from questions of social justice. 2. The mental health system is in need of radical reform. 3. We must fund life, not services. 4. Current government policy is very dangerous. 5. Mental health professionals are confronted by an enormous ethical challenge.
  5. 5. 1. Mental health & social justice
  6. 6. 1. Income inequality 2. Debt 3. Stigma 4. Multiple social problems 5. Real poverty If mental illness is an illness then its an illness that requires social justice as part of the cure; for it is linked closely to...
  7. 7. Income inequality is correlated with mental illness
  8. 8. 45% of people in debt have mental health problems compared to 14% of people who are not in debt Developing unmanageable debt is associated with an 8.4% risk of developing a mental health problem compared to 6.3% for people without financial problems (i.e. a third higher) Relative risks for people in debt: alcoholism (2x), drug addiction (4x), suicidal ideation (2x) Professor Martin Knapp, 2012 Tizard Lecture Debt is correlated with mental illness
  9. 9. Chick Collins on the ‘Scottish Effect’ Social stigma is correlated with mental illness
  10. 10. Mental illness intersects with many other social problems
  11. 11. Managing a serious health condition 64% Finding a safer place to live 27% Living with childhood abuse 51% Didn’t finish their education 76% Recent experience of domestic violence 85% Fractured family (for those with young families) 66% Children experienced abuse (for those with children) 55% Living with a severe level of mental illness 55% Living with some mental illness 91% History of drug or alcohol misuse 52% Victim of crime 41% Perpetrator of crimes 39% Worried by debt or lack of money 65% Of 44 women working with WomenCentre:
  12. 12. Service label n Urgent problem n Real need n Victim of domestic violence 55 Debt 50 Better self-esteem 64 Mentally Ill 39 Housing 48 To overcome past trauma 54 Criminal 35 Benefits 46 To manage current trauma 51 Poor Mother 33 Health 37 To stop being bullied 50 Misuses Alcohol 24 Rent 32 Guidance 50 Uses Drugs 22 Criminal Justice Advocate 24 Relationship skills 45 Violent 19 Dentistry 8 Mothering skills 26 Chronic Health Condition 16 Others 3 Others 1
  13. 13. The multiple reinforcing erosion of personal resilience Mental illness is linked to real poverty
  14. 14. 2. The mental health system
  15. 15. 1. Where is the recognition of the social justice factors that impact on mental health? 2. Can we be confident in the effectiveness of medicine to treat mental illness? 3. Can we be confident in the helpfulness of the mental health system? 4. Do we know how often do our crisis responses make things worse? Does our current response to mental illness make sense?
  16. 16. There are lots of services; but how useful are they?
  17. 17. We spend people’s money for them on things they wouldn’t really buy for themselves
  18. 18. Rather than reducing inequalities itself, the initiatives aimed at tackling health or social problems are nearly always attempts to break the links between socio-economic disadvantage and the problems it produces. The unstated hope is that people - particularly the poor - can carry on in the same circumstances, but will somehow no longer succumb to mental illness, teenage pregnancy, educational failure or drugs. Wilkinson & Pickett, The Spirit Level We ignore the social and economic dimension
  19. 19. Many treatments lack supporting clinical evidence
  20. 20. We often create more crises by inappropriate responses
  21. 21. Annually, there are 10,000 people placed out of area for mental health reasons and approximately 11,000 people with learning disabilities are also placed out of area per year. Nationally, the National Mental Health Development Unit (NMHDU) estimated that out of area placements for mental health cost £690 million per annum, therefore the combined cost of out of are placements is likely to be more than twice that amount, that is over £1.5 billion (NMHDU, 2011). Of the total number of residential and nursing care placements for mental health each year, 22% are out of area. Alakeson and Duffy, Health Efficiencies We move people and money out of communities
  22. 22. These findings [better long-term outcomes for schizophrenia in developing countries] still generate some professional contention and disbelief, as they challenge outdated assumptions that generally people do not recover from schizophrenia and that outcomes for western treatments and rehabilitation must be superior. However, these results have proven to be remarkably robust, on the basis of international replications and 15-25 year follow-up studies. Explanations for this phenomenon are still at the hypothesis level, but include: 1. greater inclusion or retained social integration in the community in developing countries, so that the person retains a role or status in the society 2. involvement in traditional healing rituals, reaffirming community inclusion and solidarity 3. availability of a valued work role that can be adapted to a lower level of functioning 4. availability of an extended kinship or communal network, so that family tension and burden are diffused, and there is often less negatively 'expressed emotion' in the family. Dr Alan Rosen from Destigmatising day-to-day practices: What Can Developed Countries learn from Developing Countries? World Psychiatry 2006, 5: 21-24
  23. 23. We don’t pay attention to the source of people’s real wealth
  24. 24. 3. Mental health reform
  25. 25. 1. Peer support 2. Personalised support 3. Relationship work 4. Entitlements and control 5. A focus on supporting citizenship We can see some of the main elements of a reformed mental health system
  26. 26. Fund Life, not services. ...there is a role for services - but in an equal partnership with people and communities
  27. 27. Peer support is critical and will guide us to better solutions
  28. 28. “Don't forget to tell them that we had our first PFG camping trip last Sunday - it was amazing......we are planning Mad Fest which will be our mental health festival for next July. Music group started and we have our own band...........we also now have a community garden. And we have started a partnership with the church to have the church hall to do other crazy things in - we are doing pull up a pew - taking a church seat with us to have a cuppa and a chat about how people are feeling. Just incorporating into a proper company and Our Jude is now the Chair of Doncaster CCG's Mental Health Alliance (A woman who didn't leave the house for five years)”
  29. 29. Support needs to fit the person, not the reverse
  30. 30. Knitting together the bond of trust
  31. 31. 1. Start with the whole woman - gendered and holistic 2. Offer a positive and comprehensive model of support - every woman is a one-stop-shop 3. Build a bond of trust - create the means for woman to do real work together 4. Be a new kind of community - women, working together, to improve lives and communities.
  32. 32. I used to work in the fashion design industry as a product developer until I became ill. This was a hard time in my life. I was diagnosed with paranoid schizophrenia... I am now on the road to recovery my budget has reduced. I have updated my plan myself and this has given me the opportunity to talk about what I want for the future. The opportunity to be creative is very important to me and is something that keeps me well. I now receive a little support and a one off payment which I use to help me to buy equipment to make jewellery. I hope that I will eventually be able to teach other people how to make jewellery to give something back. My goal is to start up my own jewellery business and be financially self-supporting, and the recovery team is helping me with this. Without the support that I have I would still be wondering where my life is going, but now I have hopes for the future. I would definitely recommend considering a personal budget. You can really make it work for you in a way that I didn’t know was possible. I feel lucky that I have been able to get back some of the life I have lost. From Health Efficiency by Alakeson & Duffy
  33. 33. Transportation 13% Crafts 2% Computers and accessories 12% Licenses/ certification 2% Dental services 11% Entertainment 2% Medication management services 8% Vision services 2% Psychotropic medications 8% Furniture 1% Mental health counselling 8% Non-mental health medical 1% Housing 7% Camera and supplies 1% Massage, weight control, smoking cessation 5% Education, training, materials 1% Utilities 3% Haircut, manicure etc. 1% Travel 3% Pet ownership 1% Equipment 3% Supplies and storage <1% Clothing 2% Other <1% Food 2% Total 100%
  34. 34. 1. Purpose - a life of meaning 2. Freedom - directing my own life 3. Money - having enough on which to build 4. Home - being where I belong 5. Help - that fits me 6. Life - getting stuck in 7. Love - getting it and giving it Citizenship is the key
  35. 35. There are eight degrees of charity, one higher than the other. The highest degree, exceeded by none, is that of the person who assists a poor Jew by providing him with a gift or loan or by accepting him into a business partnership or by helping him find employment - in a word, by putting him where he can dispense with other people's aid. With reference to such aid, it is said, “You shall strengthen him, be he a stranger or a settler, he shall live with you” (Lev. 25:35), which means strengthen him in such manner that his falling into want is prevented. Maimonides
  36. 36. 4. The growing crisis
  37. 37. Mental health will deteriorate as 1. Inequality increases 2. Stigmatisation increases 3. Real poverty increases 4. Debt increases 5. Local power and control decreases
  38. 38. ‘Austerity’ is not the problem.
  39. 39. The financial crisis was not caused by welfare spending. It was caused by over-lending to individuals to support excessive house price growth. It is a bubble politicians cannot afford to burst.
  40. 40. Child Benefit freeze Abolition of Sure Start Maternity for second and subsequent children Change to CPI indexation of benefits Reductions in support for carers Replacing DLA with PIP Child Benefit clawback from higher rate taxpayers Time-limiting of contributory ESA Transfer of Social Fund to local government Council Tax Benefit – 10% reduction and localisation Extension of JSA lone parents with a youngest child aged 5-6 Housing Benefit cuts Household Benefit cap Abolition of the Independent Living Fund Continued use of ATOS or others Universal Credit Reductions in ‘Access to Work’ funding Closure of Remploy services Abolition of the Child Trust Fund Tax credit changes Abolition of the Health in Pregnancy Grant Abolition of the Child Trust Fund Abolition of the ESA youth rules
  41. 41. £72 billion of cuts
  42. 42. Most cuts fall in two areas:
  43. 43. This process will further centralisation
  44. 44. Q: Why is this happening?
  45. 45. A: Politics As Usual (PAU)
  46. 46. Possible explanations include: Existing patterns of prejudice and stigma Fragmentation of advocacy groups Dependency of charity sector on government Complexity of welfare system Ignorance about our rights Pandering to key electoral groups Corruption or lobbying by profit-making groups
  47. 47. Then did all the grants and the subsidies, the benefits and the bargain offers pass over these poverty-stricken peasants when Ingolfur Angerson's ideals came to fruition? What is one to say? It so happens that it signifies little though a penniless crofter be offered a grant from the Treasury towards the cost of tractors and modern ploughs... The fact is that it is utterly pointless to make anyone a generous offer unless he is a rich man; rich men are the only people who can accept a generous offer. To be poor is simply the peculiar human condition of not being able to take advantage of a generous offer. The essence of being a poor peasant is the inability to avail oneself of the gifts which politicians offer or promise and to be left at the mercy of ideals which only make the rich richer and the poor poorer. Halldor Laxness
  48. 48. 5. The challenge for professionals
  49. 49. How should mental health professionals respond when government is dangerously wrong?
  50. 50. How do we respond 1. The need for humility 2. The danger of complicity 3. The imperative to facilitate and connect 4. The possibility of campaigning
  51. 51. The future professional?
  52. 52. And we ALL need peer support It is easy to talk about cooperation, but in reality we are in our current mess because it is hard to connect, develop shared interests and overcome jealousies and conflicts. But, if we are not building, we are destroying
  53. 53. 1. Human Rights - Better fundamental legislation 2. Clear Entitlements - Its ‘my budget’ 3. Avoid Crisis - Family support, lower thresholds 4. Full Access - No ‘special’ funding for services 5. Choice & Control - Freedom, capacity 6. Fair Incomes - Enough for citizenship 7. Fair Taxes - No ‘special taxes’, no charges 8. Sustainability - Rethink health/social care split
  54. 54. The power of choosing between good and evil is within the reach of all Origen
  55. 55. For more information: Web: Twitter: @CforWR and @simonjduffy Blog: Facebook: centreforwelfarereform Campaign: © Simon Duffy. Rights Reserved. Full copyright details at