Does our advocacy need a crisis to be effective?

Allison and colleagues discuss the role for, and importance of, health professionals engaging in advocacy for improving mental health services (Allison et al., 2014). As these authors point out, services have been transformed in recent decades. The advocacy that has contributed to major injections of resources has almost always been accompanied by generating a public view that the sector is in crisis.

In 1992, when the first National Mental Health Policy and National Mental Health Plan were endorsed, the Human Rights and Equal Opportunities Commission inquiry (the Burdekin inquiry) was relentlessly identifying and publicising major shortcomings in services. In 1998, when the newly elected Commonwealth Coalition Government endorsed the Second National Mental Health Plan, the Port Arthur shootings had (inaccurately) focused attention on mental health issues. In 2006, the Council of Australian Governments (COAG) endorsed a National Action Plan for Mental Health, with the Mental Health Council of Australia’s Not for Service report, a Senate inquiry and the treatment of individuals such as Cornelia Rau highlighting failures in services. In 2011, the AUD$2.2 billion investment in mental health over 5 years was preceded by two Senate reports (in 2008 and 2010) addressing service deficiencies, the highly public resignation of the Chair of the Commonwealth Government’s National Advisory Commission on Mental Health and widespread lobbying by individuals such as the 2010 Australian of the Year and advocacy groups such as GetUp!.

There are always many issues competing for government attention and funding and as Allison and colleagues point out politics is a field where ‘everyone exaggerates everything all of the time’. They go on to comment that ‘exaggeration … appears necessary and expected in the political context [and] it may require psychiatrists to move beyond the strict and often incomplete evidence-base for mental health services reform’. Do we need to exaggerate how bad things are to get attention?

Governments usually take action in a particular area when there is a coalescence of three things – a significant problem, a policy solution to that problem and an environment where action is politically expedient. No doubt the latter, the political imperative to do something, can be driven by a sense of crisis and an urgency to address the problem, especially when the problem and its consequences are being repeatedly highlighted in the media.

All health services have failures and personal tragedies. Mental health may well have more than its share due to its legacy of marginalisation and neglect. However, other areas of health seem to be able to advocate with more of a balance between highlighting what has worked, what needs fixing and what more can be achieved. How do we balance the two realities in mental health – that reform has, in aggregate, produced an improvement in the ‘problem’ of suboptimal mental health care but that this ‘problem’ has not been fixed and much more needs to be done? Is it possible to escalate mental health to the threshold where governments will take action without having to rely disproportionately on presenting the system as being in crisis and its services as failing? While the ‘crisis’ approach might obligate governments to do something (reluctantly), it devalues achievements and damages the morale of those working in services, worsens public (and political) scepticism about mental health and impacts adversely on the recruitment and retention of good staff.

Fortunately, the way the mental health sector does advocacy is changing. The 2006 and 2011 reforms referred to above saw more sophisticated political advocacy campaigns (much of it working behind the scenes) than in the past. The 2011 reforms required sustained advocacy but with less of an emphasis on personal tragedy. There continue to be service failures and tragedies and these get aired, but the advocacy is starting to more selectively target those individuals and groups who can help open what political scientists refer to as ‘the policy window’, and are emphasising the solutions as well as the problems. What remains rare is to highlight the successes as part of this package. It is almost as if we fear that doing this will take the pressure off government to act. But if the cost of getting more funding is damage to the morale and reputation of the sector, and the staff and services we rely on to deliver treatment and care, what do we really gain for the consumer? There are too many examples of funding going up and quality of care remaining stagnant or going down. The reasons for this are complex to be sure, but a barrage of unconstructive criticism doesn’t help. Cancer and cardiovascular services, for example, seem to get resourced with a better balance in their advocacy.

As the mental health sector becomes more sophisticated, and the stigma and discrimination that surrounds mental illness lessens, we should emphasise our successes, identify the deficiencies and highlight the benefits that will accrue to consumers and their families from innovative solutions. Governments like to be associated with success, not only the hope of success and not always the compulsion to intervene in a crisis.

See Viewpoint by Allison et al., 2014, 48(9): 802–804.