Outstanding questions from the Mental Health Royal Commission: Stigma and Discrimination
It’s well known that mental health discrimination occurs across our community, including our mental health system.
The Royal Commission into Victoria’s Mental Health System identified it in the community, workplace, and mental health system. But there are other examples in areas peripheral to the mental health system and often behind closed doors. For example, there are common reports of discrimination in supported residential settings (in terms of restrictive environments), schools (the use of seclusion and restraint on children) and in the criminal justice system (often a lack of access to quality mental healthcare).
Notably, the Chapter takes a pluralistic approach to mental health and well-being by acknowledging that a diagnosis is a stigmatizing process for many people. It draws the reader’s attention to research on how biogenetic explanations of mental health can often worsen, rather than improve, people’s experience of stigma (pp 549-550, Vol 3). This is consistent with the testimony of Ro Allen (Commissioner for the LGBTIQ+ Victorian community), which pointed to how the mental health system has routinely pathologised gender identity, intersex status, and sexual orientation, and that homosexuality remained a mental illness and crime until very recently (p 542, Vol 3).
The Chapter seems to have struggled with the terms of reference, taking a more conservative and less systemic approach to addressing stigma and discrimination. Some more transformative actions appeared to the Commission to be outside their terms of reference (pp 566-567, Vol 3).
The recommendation in 41 states:
The Royal Commission recommends that the Victorian Government:
1. fund and support the Mental Health and Wellbeing Commission (refer to recommendation 44) to work with a network of partners, including research organisations, to lead the design and delivery of anti-stigma programs that:
a. continue on a long-term basis; and
b. aim to reduce the impact of stigma in a range of settings including, but not limited to, healthcare settings, workplaces and schools.
2. design and deliver an anti-stigma grants program to:
a. support community-led organisations and community members to deliver projects that challenge stigma in Victorian settings and communities; and
b. focus, as an immediate priority, on communities and social groups at increased risk of stigma.
3. conduct a comprehensive evaluation of anti-stigma efforts to:
a. develop evidence about effective ways to address mental health stigma across Victoria;
b. inform the design and delivery of anti-stigma programs.
4. support and establish mechanisms to:
a. address systemic issues of mental health discrimination;
b. enhance individual access to legal protection from mental health discrimination; and
c. enable one or two independent legal services with a demonstrated connection or ability to connect with people with lived experience of mental illness or psychological distress to initiate legal claims, including test cases relating to systemic mental health discrimination
There are many threads to take this conversation. I am most excited about the opportunity for consumer-led (part of community-led) research and anti-stigma campaigns and the prospect for greater legal protections, which I argue should be achieved through non-legal advocacy.
Consumer-led stigma campaigns
The Chapter acknowledges that too often, stigma campaigns are designed and delivered without consumers' input or leadership (pp 550-552, Vol 3). This has often focused on overly clinical framings of the problem, where more emancipatory and human rights-oriented approaches to stigma reduction would be helpful.
In providing grants, there will be opportunities for consumers to lead, or at minimum be equal partners, in campaigns to address stigma. Anything less than co-designed approaches to stigma campaigns will be inappropriate in light of the Royal Commission's commentary. And as consumers are the most affected by stigma, any co-design processes should be heavily weighted to their representation.
I am personally excited by the prospect of consumer, survivor, activist groups informing the public through campaigns such as:
The stigma and discrimination they experience in various domains of public life
Different ways to understand and respond to distress – such as Hearing Voices or Open Dialogue approaches – that are less stigmatising for some, and
How stigma and discrimination intersect with other parts of people’s experiences (gender identity, Aboriginal Victorians, sexual orientation), and the responsibility of the community to act better to prevent it.
Time will tell whether these are the kinds of grants made, but I encourage consumer groups to be proactive in seeking them out.
Legal protections for discrimination
Though recommendation (41.4.b) speaks of legal protection, I think there is an opportunity for this to involve non-legal advocacy. Non-legal advocacy can take many different forms, but often supports individuals affected by an issue to understand their legal rights, their options to address those, and have support to communicate those preferences wherever they wish. Non-legal advocates can inform a person of what the law says, but must refrain from providing legal advice.
There are reasons to believe that non-legal advocacy will be crucial to address stigma and discrimination. There is already strong evidence of its value in compulsory mental health settings, where rights restrictions are often at their greatest. [1] This complements existing non-legal advocacy in disability settings (often by the disability community themselves) [2], but can also assist people with housing, social security, child-protection and other issues while experiencing mental health problems [3].
Having worked in discrimination policy, I see that while there is value in legal protections, the area of non-legal advocacy to navigate stigmatising and discriminatory systems is crucial. The value of an advocate – in particular someone with lived experience – is of immense value. First, advocates often “walk alongside” people experiencing harm, with many reporting (such as in Independent Mental Health Advocacy’s independent evaluation), that it was valuable to have someone “in their corner”. The equal nature of non-legal advocacy relationships – built on the explicit framework that the consumer is the expert – is something that we know works. Second, advocates with lived experience also provide an opportunity to address the sense of isolation and stigma inherent in many systems by ensuring that the person affected does not feel alone and has peers to support them. Third, non-legal advocates come to understand the machinery of systems, as they spend more time navigating them than instructing in courts and tribunals. This knowledge becomes invaluable to affect systemic change.
There are many more reasons for this, but I am hopeful that this recommendation 41.4.b enables trials of non-legal advocacy services to address stigma and discrimination.
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Disclosure: I have previously been an advocate at two non-legal advocacy services (VMIAC & IMHA) and am currently on VMIAC’s Committee of Management.
[1] Maylea, C., Alvarez-Vasquez, S., Dale, M., Hill, N., Johnson, B., Martin, J., ... & Weller, P. (2019). Evaluation of the Independent Mental Health Advocacy Service (IMHA). Weller, P., Alvarez-Vasquez, S., Dale, M., Hill, N., Johnson, B., Martin, J., ... & Thomas, S. (2019). The need for independent advocacy for people subject to mental health community treatment orders. International journal of law and psychiatry, 66, 101452.
[2] Law Council of Australia, ‘People with Disability’, Justice Project – Final Report (2018) 50-1
[3] Law Council of Australia, ‘People with Disability’, Justice Project – Final Report (2018) 50-1; Maylea, Chris; Thomas, Sherie; Bashfield, Lucy; Kuyini, Bawa; Costello, Susie; Singh, Meena (2020) Midterm Evaluation of Independent Family Advocacy and Support pilot service (IFAS), Melbourne: Social and Global Studies Centre, RMIT University.
