Open door no restraint
by Keith Bryant
The relationship between language, practice and pathways in mental health has always interested me, particularly because the experiences that most of us have in life are often excluded from the labels and terms that get used in a biomedical model of mental health care.
The World Health Organisation defines the social determinants of health as ‘the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age’.
And with these conditions, a number of factors can emerge that can have an impact on anyone – from job insecurity and unemployment to lack of access to housing, barriers to accessing education, lack of physical or cultural safety, isolation, loneliness and trauma – to name a few.
These factors are often overlooked in our approach to mental health – meaning that our system has not demonstrated a widespread ability to move away from the illness / diagnosis paradigm to the extent that many families and communities would hope. Thinking through what may help a person to recover from an adverse event, or re-gain their strength, by using the resources of their close loved ones, family or their community is a missed opportunity.
An article in Perspectives from the Medical Journal of Australia in 2024 explains the traditional model of care like this:
An individual presents with a cluster of symptoms, a GP or psychiatrist formulates them into a mental disorder diagnosis and offers treatment mainly in the forms of pharmacotherapy or psychotherapy.
While this formula doesn’t describe the way everybody now works, it is still the most commonly documented experience that people have with our system of care. And because of this reductionist approach, the door to community-based care or support from friends, peers and family is rarely opened, before, during or after any instances of clinical engagement.
The concept that everybody needs to be diagnosed, treated and cured just isn’t leading to better outcomes. In-fact we now know that a higher density of mental health professionals compared to other carers does not shift the dial for those who are in a state of distress.
The WHO has produced a strong body of work to promote the importance of person -centred, recovery-oriented and rights-based support in mental health.
And importantly from my point of view is the fact that the community-based mental health services that feature in the WHO documents show lower costs of service provision than comparable mainstream services.
Unfortunately, we don’t have a consistent understanding of what person-centred, recovery-oriented and rights-based should look like, even though our services often use the language of community inclusion, dignity, autonomy, agency and empowerment.
My understanding is that this is what we want to do: consider people in the context of their whole lives, respecting their will and preferences in treatment, implementing alternatives to coercion and promoting people’s rights to participation and community inclusion.
Trieste in Italy is an example that a number of psychiatrists and clinicians reference in our gatherings at ODC. ‘We want to be Trieste.’ The aspiration is there. The challenge is ‘How do we get there when nobody has time to move away from crisis mode and into change mode?’
Staff at the Community Mental Health Service in Trieste in Italy (which covers a population of 236K people) work collaboratively with local health and social services, the judicial system, cultural organisations, local authorities and peer and social networks. There are no waiting lists and people get a response within two hours. The Centres all have an open door policy and around 50% of the work that staff do takes place in the community. Services work in partnership with non-profit organisations, volunteers and peers and carers who are familiar to the people needing support.
WHO reports that: The number of people subjected to involuntary treatment in Trieste dropped from 150 in 1971 to 18 in 2019. And with the overall transformation of services from the 1970s until today, several studies have shown that the outcomes for people using the services have significantly improved and that the costs of providing care and support have diminished.
This is so positive. And what interests me is that it doesn’t have to be that complicated – although working with systems is admittedly complex.
The Trieste example shows that we can all address stigma and embrace a more holistic approach to mental health that involves family and community and avoids the emphasis on diagnosing, treating, and curing.
Keith Bryant