Talk given at the RCN's International Conference for Psychiatric Nursing on mental health reform. The talk describes the ethical challenge facing nurses as government policy both undermines mental health and avoids the need for meaningful reform. Can nurses work with people to bring about the necessary changes?

1. Personal Responsibility & Social Justice
key elements in mental health reform
Dr Simon Duffy ￭ The Centre for Welfare Reform ￭ 6th September 2013 ￭
International Network for Psychiatric Nursing Research, RCN, University of Warwick

2. Dr Simon Duffy
• Worked with disabled people
for 24 years, invented personal
budgets and developed self-
directed support
• Philosopher, with an interest in
ethics and social justice,
• NOT an expert in mental
health.

3. The Centre for Welfare Reform
• Welfare state is good - it is just
designed wrong.
• Move away from meritocratic
thinking, instead value human
diversity & equality
• New thinking must promote
justice, citizenship, family &
community.
• Innovate to build practical
alternatives

4. 1. Questions of mental health cannot be separated
from questions of social justice.
2. The mental health system is in need of radical
reform.
3. We must fund life, not services.
4. Current government policy is very dangerous.
5. Mental health professionals are confronted by an
enormous ethical challenge.

5. 1. Mental health &
social justice

6. 1. Income inequality
2. Debt
3. Stigma
4. Multiple social problems
5. Real poverty
If mental illness is an illness then its an illness
that requires social justice as part of the cure;
for it is linked closely to...

8. Income inequality is correlated with mental illness

9. 45% of people in debt have mental health problems compared
to 14% of people who are not in debt
Developing unmanageable debt is associated with an 8.4% risk
of developing a mental health problem compared to 6.3% for
people without financial problems (i.e. a third higher)
Relative risks for people in debt: alcoholism (2x), drug addiction
(4x), suicidal ideation (2x)
Professor Martin Knapp, 2012 Tizard Lecture
Debt is correlated with mental illness

10. Chick Collins on the ‘Scottish Effect’
Social stigma is correlated with mental illness

12. Mental illness intersects with many other social problems

13. 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%
Of 44 women working with WomenCentre:

14. 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

15. The multiple reinforcing erosion of personal resilience
Mental illness is linked to real poverty

16. 2. The mental
health system

17. 1. Where is the recognition of the social justice
factors that impact on mental health?
2. Can we be confident in the effectiveness of
medicine to treat mental illness?
3. Can we be confident in the helpfulness of the
mental health system?
4. Do we know how often do our crisis responses
make things worse?
Does our current response to mental illness
make sense?

18. There are lots of services; but how useful are they?

19. We spend people’s money for
them on things they wouldn’t
really buy for themselves

20. Rather than reducing inequalities itself, the initiatives aimed at
tackling health or social problems are nearly always attempts
to break the links between socio-economic disadvantage and
the problems it produces. The unstated hope is that people -
particularly the poor - can carry on in the same circumstances,
but will somehow no longer succumb to mental illness,
teenage pregnancy, educational failure or drugs.
Wilkinson & Pickett, The Spirit Level
We ignore the social and economic dimension

21. Many treatments lack supporting clinical evidence
http://clinicalevidence.bmj.com

23. We often create more crises by inappropriate responses

24. Annually, there are 10,000 people placed out of area for mental health
reasons and approximately 11,000 people with learning disabilities are
also placed out of area per year. Nationally, the National Mental Health
Development Unit (NMHDU) estimated that out of area placements for
mental health cost £690 million per annum, therefore the combined cost
of out of are placements is likely to be more than twice that amount, that
is over £1.5 billion (NMHDU, 2011). Of the total number of residential and
nursing care placements for mental health each year, 22% are out of
area.
Alakeson and Duffy, Health Efficiencies
We move people and money out of communities

26. 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

28. We don’t pay attention to the source of people’s real wealth

29. 3. Mental health
reform

30. 1. Peer support
2. Personalised support
3. Relationship work
4. Entitlements and control
5. A focus on supporting citizenship
We can see some of the main elements of a
reformed mental health system

32. Fund Life,
not services.
...there is a role for
services - but in an
equal partnership
with people and
communities

33. Peer support is critical and will guide us to better solutions

34. “Don't forget to tell them that we had our first PFG camping trip
last Sunday - it was amazing......we are planning Mad Fest which
will be our mental health festival for next July. Music group
started and we have our own band...........we also now have a
community garden. And we have started a partnership with the
church to have the church hall to do other crazy things in - we are
doing pull up a pew - taking a church seat with us to have a
cuppa and a chat about how people are feeling. Just
incorporating into a proper company and Our Jude is now the
Chair of Doncaster CCG's Mental Health Alliance (A woman who
didn't leave the house for five years)”

36. Support needs to fit the person, not the reverse

40. Knitting together the bond of trust

41. 1. Start with the whole woman - gendered and holistic
2. Offer a positive and comprehensive model of
support - every woman is a one-stop-shop
3. Build a bond of trust - create the means for woman
to do real work together
4. Be a new kind of community - women, working
together, to improve lives and communities.

45. I used to work in the fashion design industry as a product developer
until I became ill. This was a hard time in my life. I was diagnosed
with paranoid schizophrenia...
...as I am now on the road to recovery my budget has reduced. I
have updated my plan myself and this has given me the opportunity
to talk about what I want for the future. The opportunity to be
creative is very important to me and is something that keeps me
well. I now receive a little support and a one off payment which I
use to help me to buy equipment to make jewellery. I hope that I
will eventually be able to teach other people how to make jewellery
to give something back. My goal is to start up my own jewellery
business and be financially self-supporting, and the recovery team is
helping me with this.
Without the support that I have I would still be wondering where my
life is going, but now I have hopes for the future. I would definitely
recommend considering a personal budget. You can really make it
work for you in a way that I didn’t know was possible. I feel lucky
that I have been able to get back some of the life I have lost.
From Health Efficiency by Alakeson & Duffy

47. 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%

51. 1. Purpose - a life of meaning
2. Freedom - directing my own life
3. Money - having enough on which to build
4. Home - being where I belong
5. Help - that fits me
6. Life - getting stuck in
7. Love - getting it and giving it
Citizenship is
the key

52. There are eight degrees of charity, one higher than the
other. The highest degree, exceeded by none, is that of
the person who assists a poor Jew by providing him
with a gift or loan or by accepting him into a business
partnership or by helping him find employment - in a
word, by putting him where he can dispense with
other people's aid. With reference to such aid, it is said,
“You shall strengthen him, be he a stranger or a settler,
he shall live with you” (Lev. 25:35), which means
strengthen him in such manner that his falling into
want is prevented.
Maimonides

53. 4. The growing
crisis

54. Mental health will deteriorate as
1. Inequality increases
2. Stigmatisation increases
3. Real poverty increases
4. Debt increases
5. Local power and control decreases

55. ‘Austerity’ is not
the problem.

56. The financial crisis was not
caused by welfare spending.
It was caused by over-lending to
individuals to support excessive
house price growth.
It is a bubble politicians cannot
afford to burst.

58. Child Benefit freeze
Abolition of Sure Start Maternity for second
and subsequent children
Change to CPI indexation of benefits Reductions in support for carers
Replacing DLA with PIP
Child Benefit clawback from higher rate
taxpayers
Time-limiting of contributory ESA Transfer of Social Fund to local government
Council Tax Benefit – 10% reduction and
localisation
Extension of JSA lone parents with a
youngest child aged 5-6
Housing Benefit cuts Household Benefit cap
Abolition of the Independent Living Fund Continued use of ATOS or others
Universal Credit Reductions in ‘Access to Work’ funding
Closure of Remploy services Abolition of the Child Trust Fund
Tax credit changes Abolition of the Health in Pregnancy Grant
Abolition of the Child Trust Fund Abolition of the ESA youth rules

62. £72 billion of cuts

63. Most cuts fall
in two areas:

70. This process will further centralisation

71. Q: Why is this happening?

72. A: Politics As Usual (PAU)

73. Possible explanations include:
Existing patterns of prejudice and stigma
Fragmentation of advocacy groups
Dependency of charity sector on government
Complexity of welfare system
Ignorance about our rights
Pandering to key electoral groups
Corruption or lobbying by profit-making groups

75. Then did all the grants and the subsidies, the benefits and the
bargain offers pass over these poverty-stricken peasants when
Ingolfur Angerson's ideals came to fruition? What is one to say? It
so happens that it signifies little though a penniless crofter be
offered a grant from the Treasury towards the cost of tractors and
modern ploughs...
The fact is that it is utterly pointless to make anyone a generous
offer unless he is a rich man; rich men are the only people who can
accept a generous offer. To be poor is simply the peculiar human
condition of not being able to take advantage of a generous offer.
The essence of being a poor peasant is the inability to avail oneself
of the gifts which politicians offer or promise and to be left at the
mercy of ideals which only make the rich richer and the poor
poorer.
Halldor Laxness

76. 5. The challenge
for professionals

77. How should mental health
professionals respond when
government is dangerously
wrong?

78. How do we respond
1. The need for humility
2. The danger of complicity
3. The imperative to facilitate and connect
4. The possibility of campaigning

82. The future professional?

83. And we ALL need peer support
It is easy to talk about cooperation, but in
reality we are in our current mess because
it is hard to connect, develop shared
interests and overcome jealousies and
conflicts.
But, if we are not building, we are
destroying

85. 1. Human Rights - Better fundamental legislation
2. Clear Entitlements - Its ‘my budget’
3. Avoid Crisis - Family support, lower thresholds
4. Full Access - No ‘special’ funding for services
5. Choice & Control - Freedom, capacity
6. Fair Incomes - Enough for citizenship
7. Fair Taxes - No ‘special taxes’, no charges
8. Sustainability - Rethink health/social care split

86. The power of choosing
between good and evil is
within the reach of all
Origen

87. For more information:
Web: www.centreforwelfarereform.org
Twitter: @CforWR and @simonjduffy
Blog: www.simonduffy.info
Facebook: centreforwelfarereform
Campaign: www.campaignforafairsociety.org
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