Mental health advocacy and rhetoric in our time

Following the series in this Journal on evidence-based mental health reform (Jorm and Malhi, 2013), a further Viewpoint article is published here that addresses how mental health advocacy may support ongoing reform (Allison et al., 2014), particularly in the aftermath of the 2014 Australian Federal Budget’s selective austerities. In making their case, these authors contrast scholarship (‘skeptical and incremental’) and rhetoric (‘exaggeration’) with implied disparagement of the latter. Rhetoric, however, is much subtler than this simple interpretation, and it may be of value to examine its elements in the current context in which mental health advocates may seek to persuade governments to continue key mental health reforms.

Almost two and a half millennia have passed since Aristotle outlined the key elements of rhetoric that are still germane today. He described three means of persuasion: logos, ethos and pathos. The first of these refers to rationality, strength of evidence, and the use of sound reasoning in putting forward a convincing argument. There is no space here to review the varieties of evidence for the potential benefits of certain mental health reforms, as sketched briefly in the series appearing in this journal (Carr and Waghorn, 2013; Castle, 2013; Jorm and Malhi, 2013; Whiteford et al., 2013), so no further comment will be offered on the state of the evidence base.

The second element of persuasion is the credibility, trustworthiness and status of the persuader – and how convincing he or she might be. Here the argument of Allison et al. (2014) runs into difficulties. They propose a key role for the College and the Australian Medical Association (AMA)in mental health advocacy. While valuable up to a point, the credibility of advocacy by these organizations will inevitably be called into question on the basis of their relatively narrow (medical) perspective, potential accusations of self-interest, and their inability to speak for the wide range of mental health stakeholders – patients (consumers), families, friends and carers, non-government organizations in mental health support and service provision, and other relevant professional, educational and research bodies, and so on.

Whereas each stakeholder is free to set its own priorities, mental health advocacy must speak with one voice. In order for government not to exploit potential divisions in mental health advocacy arising from potentially conflicting priorities, and thereby turn its back on continuing systematic reform (or merely grease the squeakiest wheel), it is critical that a broad-based coalition of stakeholders take a single, unified message to government and deliver it effectively and repeatedly, preferably through a paid professional lobbyist, and that individual stakeholder groups stand solidly in support of this coalition. Such a coalition is embodied by the Mental Health Council of Australia (MHCA), of which the College and AMA are members. However, being largely government-funded, the MHCA is vulnerable to the vagaries of the government of the day, and almost certainly does not have the financial firepower to hire the best professional lobbyists. Without greater independent financial clout, it is likely always to be standing in a queue behind the miners, banks and large corporations.

The third means of persuasion, pathos, is undoubtedly the strongest, but also the most complex and unpredictable, and hence inherently risky. It refers to an immediate, palpable call to emotions and sympathies, including prejudices, and is particularly powerful when appealing to the identity and self-interest of the listener. The risks are illustrated, for example, in arguments to influence current Australian asylum-seeker policy that put forward a powerfully compassionate, humanitarian point of view; these have been easily countered by more powerful appeals to xenophobia. The result has been a hardening of political support for a morally untenable and logically contradictory policy of punishing victims of crime in order to deter the perpetrators of crime.

Allison et al. (2014) take up this element of persuasion when they refer to ‘personal relationships’ and politicians being open to persuasion when they have ‘direct experience with a condition and understand(s) the impact’. As above, this can be a double-edged rhetorical sword, since some personal experiences may turn an individual towards a negative, stereotyped view of mental illness, leaving the person impervious to an alternative view. So, whoever seeks to advocate for continuing mental health reform needs to recognize both the strength and the risks of the third element of persuasion, and carefully weigh up the potential costs and benefits of using it.

A final consideration in mental health advocacy is to be aware of the political-economic context into which this country, along with most others, is moving. This is the age of big capital. The striking inequities in the 2014 Australian Federal Budget signal that the ‘age of entitlement’ may indeed be over for the sick, disabled, poor and disadvantaged, but not for big banks, mining companies, large corporations and rentiers. As the distributions of income and wealth become more inequitable with time, we can look forward to a growing underclass of poor among which the burden of mental illness will inevitably grow. We will all pay a heavy price for this in the long term. Mental health advocacy may need to take a broader political and economic view than it has up to the present, and highlight the adverse mental health consequences of certain political and economic policies. For example, if we see a growing marketization of public health care, education, research and human services provision, with parallel curtailments of government spending in these areas, then the most vulnerable, the mentally ill, will likely suffer the most. Mental health advocacy will fail its constituency if it does not successfully adapt to or counter trends of this kind.

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