The optimistic new mental health policy emphasises recovery and aims to help people solve their mental health problems and re-build their working lives and relationships in a community-based approach to mental illness. Sylvia Thompson reports
'There is no difference between a physical illness and a mental illness," said Tim O'Malley, Minister of State at the Department of Health at the recent launch of A Vision for Change - report of the expert group on mental health policy. If so, why is that people often keep secret their experiences of depression, anxiety or panic attacks? Yet, when it comes to cancer, heart disease or other physical illnesses, discussion of various treatments, surgical procedures and rehabilitation programmes often becomes part of coping with and recovering from the illness.
O'Malley's comment underlies an attempt within this new policy document to normalise the experience of mental ill health and embrace the idea of recovery into our understanding of mental illness. So, rather than taking people out of their home environments and putting them in psychiatric hospitals (or mental asylums which originally were intended to be places of refuge and safety), this new model aims to keep people in their own homes or in houses in the community, giving them practical and psychological support to re-build their lives.
Alongside this community-based approach, there is a shift of emphasis away from mental and behavioural disorders having solely a biological cause to being the result of a complex interaction of biological, psychological and social causes. This shift of emphasis means that there will be an onus on all of us to understand how prolonged experiences of psychological distress - caused by such things as unemployment, relationship problems, poor housing coupled with an underlying personal vulnerability - can result in mental health problems.
Pat Brosnan, director of mental health in the HSE midwest, believes that for a community-based approach to mental health to work, we need to normalise the reality of mental ill health in our society. "In my work, I need to explore the darker side of my patients' experiences and to what extent society is in denial of these experiences."
Brosnan takes this approach a step further in that he says we all need to embrace our darker sides. "We have great difficulty in accepting the shadow side that is in all of us and we project our own fear of this into our reluctance to accept diversity in our community and, in particular, our reluctance to accept mental ill health.
"When we have the courage to face that side of ourselves, we will be in a stronger place. Mental health is everyone's business just like suicide is everyone's business."
Tackling the stigma that still exists around mental illness and mental health problems will undoubtedly be one of the most important issues to address, if A Vision for Change is to become a reality. People suffering from mental health problems or mental illnesses will simply not be able to re-integrate into community life, if their experiences are not sympathetically understood.
According to A Vision for Change, stigma and discrimination can have an even greater effect on the lives of service users than their mental health problems. "Stigma can affect people long after their mental health symptoms have been resolved. Discrimination can also lead to relapses and can intensify existing symptoms."
According to Schizophrenia Ireland, two of the biggest myths associated with mental illness are that those with severe mental illness are violent and that they don't recover from their illness. "The vast majority of violence is carried out by people who don't have a mental illness," says John Saunders of Schizophrenia Ireland. "And many people who have quite severe mental illness return to a functional state and conduct their own lives, contributing to society and the community they live in," he adds.
For community-based mental health services to work, there will also be a need for the remaining staff currently employed in psychiatric hospitals to be re-deployed into the community. They will then become part of the multidisciplinary teams of psychologists, social workers and occupational therapists who go into the homes of the service-user rather than the service-user coming to them.
The report says: "It is important not to underestimate the human interaction that is at the heart of mental health treatment and care."
Brosnan says: "The first step to effecting change is in ourselves as service-providers. We need to give staff the opportunity to stop and reflect on the profound impact they have in how they engage with their job. We need to re-establish that place of trust - that idea of asylum as a place of refuge and safety - where people can unburden themselves and know that they will be listened to."
Dr John Owens, chairman of the Mental Health Commission, acknowledges that there is low morale in parts of the mental health services.
"The process of change from hospital-based care to community-based care is well advanced already. Sometimes, people have been discharged from psychiatric hospitals without the necessary rehabilitation training and placed in hostels which then become mini-institutions. In other cases, the social and psychological rehabilitation has worked extremely well. But, the sector itself has been underprovided for, under-staffed which has resulted in a defensive, self-interested practice in some cases.
"A Vision for Change emphasises the importance of individuals' rights, dignity and citizenship. A home-based approach to dealing with acute mental illness offered by home-based nurses and visiting doctors, social workers and psychologists will help families understand illness better and the social difficulties and conflicts will become much more obvious - and therefore better managed by treatment teams."
This home-based approach to treating mental illness is already up and running in the Cavan/Monaghan region.
Dr Siobhan Barry, psychiatrist and medical director of Cluain Mhuire Family Centre in Blackrock, Co Dublin, is concerned that the community-based model may not be appropriate for those who suffer from alcohol or substance abuse.
"Alcohol-related problems are already an immense burden on the health services - representing a significant number of GP referrals and affecting accident and emergency departments and mental health services. Many of these people are seeking admission to hospitals for detoxification and problems relating to existing mental illnesses. This gets very little attention in this new policy document."
Barry also says that little attention is given to how community-based services will deal with those who suffer bad experiences from using illegal drugs such as cocaine or ecstasy.
Organisations like Mental Health Ireland have an important role in educating people about the importance of mental health. Such initiatives as the Mental Health Matters education pack for secondary schools (soon to be piloted in primary schools) offer young people opportunities to talk about mental health and mental illness. Other programmes aimed at third-level colleges alert young people to the signs of psychological vulnerability and how they can support each other and/or seek help from on-campus counsellors.
Chief executive of Mental Health Ireland Brian Howard believes the taboos around mental illness are gradually eroding. "From two surveys we have carried out, we know that there is a great level of empathy for people with mental illness. Some 73 per cent of people had a family member or friend who had experienced mental health problems," he says. The same survey revealed that 95 per cent of people felt we need to adopt a far more tolerant attitude towards people with mental illness.
So, perhaps, ironically, after much criticism of the slow rate of change from the the last mental health policy document, Planning for the Future (1984), we as a society are on the way to embracing the changes that will be required for A Vision of Change to become a reality.