SECOND OPINION:Why shelving of 'A Vision for Change' will be a good thing, writes JACKY JONES
VIRTUALLY ALL readers of HEALTHplus either know someone who has received help for a mental health problem or have sought help themselves. This is because up to 50 per cent of Irish people will experience mental health difficulties at least once in their lives. Five of the 10 leading causes of disability worldwide are due to mental health conditions such as depression and anxiety. By 2020, the World Health Organisation (WHO) estimates that the global burden of mental ill health will be heavier than heart disease.
Ireland’s current financial difficulties mean that A Vision for Change, the mental health 2006 policy document, may not be implemented. Fear not, this will be a good thing. When the document was first published, it was seen as a chance to transform mental health services. A closer analysis shows that A Vision for Change will not transform services because the most important problem, “Imbalances of power between service users and professionals need to be acknowledged and addressed”, is not actually dealt with in the policy. How these imbalances are to be addressed or even acknowledged are a mystery. Out of 168 recommendations not one addresses the power problem. Manpower, on the other hand, is dealt with 40 times throughout the document. Clearly the power of the professionals is regarded as more important than the power of service users.
Service users and their families have consistently referred to the power imbalances that prevail in the Irish mental health services. The recent RTÉ documentary, Behind the Walls, showed the powerlessness of people receiving mental health treatments and the total disregard for at least one of their human rights. Article 5 of the Universal Declaration of Human Rights says that no one shall be subjected to torture or to cruel, inhuman or degrading treatment. Health professionals claim that things have changed, but not enough it seems.
The 2004 What We Heard study by the Irish Advocacy Network found “a huge deficit in relation to . . . knowing what their rights were within the service”, with 77 per cent of mental health service users not understanding their rights under current legislation, 70 per cent having no input into their treatment plans, and 69 per cent being unaware of any rights they had to refuse treatment.
Some service users said treatments were aggressive and invasive with an overuse of medication. Only 15 per cent were informed about complaint procedures, and when they complained, a majority of outcomes were not positive. Contrast this with general complaints to the HSE where the vast majority of service users are satisfied with the outcomes. The 2004 report Speaking Your Mind also found that medication is the first, and often, only treatment option.
A Vision for Change stresses the importance of partnership between service users and service providers. There is unequivocal international evidence that power must be shared equally in successful partnerships. Misuse or abuse of power, and power imbalances, mean no partnership is possible. Shared power includes defining the problem and finding a solution together. In 1969, Sherry Arnstein argued that “since those who have power normally want to hold onto it, historically it has had to be wrested by the powerless rather than proffered by the powerful”, and that is what must happen in the Irish mental health services.
The WHO, in Empowerment in Mental Health 2010, called for the transformation of power relations between service users and professionals. “This implies that people with mental health problems have the power to set the agenda, make decisions and control resources.”
Unfortunately, the partnerships proposed by A Vision for Change are not transformative. Power imbalances exist when professionals apply their expertise arrogantly and withhold information about service user rights.
An equal partnership means professionals share their expertise openly and recognise that the service user is the expert in relation to their own illness and experience. Between them they find a solution.
Power imbalances are the main cause of the stigma that surrounds mental illness and not the behaviour of service users. Their powerlessness marks them out as being different and people of little account. This stigma will endure unless government policy redresses the balance. So let’s forget about the existing A Vision for Change policy and not waste any money on its implementation. What is needed is a slimmed down version which finally puts power between service users and professionals on an equal footing.
Dr Jacky Jones is a former regional manager of health promotion with the HSE