Simon Duffy explores the value of citizenship in reforming the welfare state and improving mental health. This talk was given at the Viscerv Conference 2016 in Melbourne.

1. Being a true equal…
Citizenship,
contribution &
mutual support
in the modern
welfare state
Dr Simon Duffy of the Centre for Welfare Reform
VICSERV Mental Health Conference 2016, Melbourne
@simonjduffy @CforWR #TowardsRecovery

2. The welfare state’s a good thing, but we’ve
designed it wrong. We try to solve social
problems with money and power and we end
up solving the wrong problems in the wrong
way. Over time we’ve created an empire of
services that protect their own interests and
undermine the possibility of better solutions.
This is causing mental illness, and many
other problems. We need to rethink the
system - and more importantly we need to
reclaim our own citizenship.
The welfare state’s a good thing, but we’ve
designed it wrong. We try to solve social
problems with money and power and we end
up solving the wrong problems in the wrong
way. Over time we’ve created an empire of
services that protect their own interests and
undermine the possibility of better solutions.
This is causing mental illness, and many
other problems. We need to rethink the
system - and more importantly we need to
reclaim our own citizenship.

3. “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professional contention and disbelief, as they challenge outdated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
Recovery rates better without mental health services

4. How did we get here?

5. We’ve tried to solve complex social problems with services

6. We’ve created a rainforest and a desert

8. Mental health improves
in a decent society

9. Black men in
Britain are 5
times more likely
to be in prison
and 17 times
more likely to be
diagnosed with a
psychotic illness.
Prejudice and racism
cause mental illness

10. “In total, across England as a whole,
the WCA disability reassessment
process during this period [2010-13]
was associated with an additional
590 suicides (95% CI 220 to 950),
279,000 additional cases of self-
reported mental health problems
(95% CI 57,000 to 500 000) and the
prescribing of an additional 725 000
antidepressant items (95% CI
406,000 to 1,045,000).”
Barr B, et al. ‘First, do no harm’: are disability
assessments associated with adverse trends in
mental health? A longitudinal ecological study J
Epidemiol Community Health 2015;0:1–7.
doi:10.1136/jech-2015-206209
Government policy causes suicide

11. Income inequality causes mental illness

12. Mental health improves
in strong communities

13. • Postnatal depression reduced by 77%
• Unemployment dropped by 71%
• Reduced fear of crime
• Childhood accident rate dropped by 50%
Community led programme of neighbourhood renewal

14. Peers with mental health problems leading community change

17. Mental health improves
with good family life

18. Lots of services, but not the right support

19. The women with the most complex needs don’t fit in services

20. 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%

22. 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

23. A partnership between women - improving mental health

24. Mental health improves
with greater citizenship

25. http://www.centreforwelfarereform.org/library/by-az/recovery-stories.html

26. “I use direct payments to go to the gym, travelling and
volunteering.” [Adam]
“The payments enable me to exercise several times a
week which has had a really positive effect on my
wellbeing as well as keeping me fit.” [Ruth]
“I now have a purpose on life and hopefully this will
lead me to have an independent life in the future.”
[Susan]
“Straight away I started singing lessons…” [RG]
“I used my direct payments to enable me to meet up
and spend time with my brother.” [Bernadette]
“…he used the money to pay for bus and taxi fares.”
[Christine]

27. “.…to pay for swimming lessons.” [S.S.S.]
“Our hope for the future is that my husband will continue
to live at home. Direct Payments plus committed and
smart professionals are the key enablers for this.”
[Fred]
“This allowed me to have a holiday with my
daughter… I also go to the theatre, meals out…
hobbies such as card making…” [Carol]
“Personal budgets have enabled us to work in
partnership with our service users to identify and access
services and resources that are meaningful to their
Recovery.” [Mandy]

28. http://www.centreforwelfarereform.org/lib
rary/by-date/active-patient.html

29. 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%
www.centreforwelfarereform.org/library/by-date/active-patient.html

31. The
deinstitutionalisation
challenge

33. The crossroads ahead for
community services…

34. Service into Community or Organisation of Community

35. Why are we consumers?

36. Origin of “Consumer” early 15c.“one who
squanders or wastes” agent noun from
consume. In economic sense, “one who
uses up goods or articles” (opposite of
producer) from 1745.
The idea of consumer negates the idea that we
- people, families and even professionals have
something to contribute.
It forgets that we make our world together.

37. Control, not choice, is what we need

38. Why not citizens?

39. The home of citizenship

40. Citizenship is beautiful for it means:
We can all be free to express who we
really are.
We all share responsibility for making
the world as good as it can be.
We can live together as equals, in all our
diversity.

41. So let’s act as citizens