872
ANZJP Correspondence
groups who can help open what political scientists refer to as ‘the policy window’, and are emphasising the solutions as well as the problems. What remains rare is to highlight the successes as part of this package. It is almost as if we fear that doing this will take the pressure off government to act. But if the cost of getting more funding is damage to the morale and reputation of the sector, and the staff and services we rely on to deliver treatment and care, what do we really gain for the consumer? There are too many examples of funding going up and quality of care remaining stagnant or going down. The reasons for this are complex to be sure, but a barrage
of unconstructive criticism doesn’t help. Cancer and cardiovascular services, for example, seem to get resourced with a better balance in their advocacy. As the mental health sector becomes more sophisticated, and the stigma and discrimination that surrounds mental illness lessens, we should emphasise our successes, identify the deficiencies and highlight the benefits that will accrue to consumers and their families from innovative solutions. Governments like to be associated with success, not only the hope of success and not always the compulsion to intervene in a crisis.
Funding
What should psychiatrists be doing to improve the mental health of the community? David J Castle1,2
implicit question about what we as psychiatrists should be doing to influence the course of mental health service development. Allison et al. (2014) are quite correct to take the 2014 Federal budget as something of a watershed, as it seems to have within it overt or covert challenges to many aspects of our society, not least welfare, education and health. Of course, psychiatrists should vociferously advocate for our patients in response to the proposed budget cuts in as far as they are likely to have a negative impact on people with a mental illness. Not only will there likely be fallout for our patients’ mental health but also for their physical health. For example, we are very conscious of the appalling statistics regarding unmet need in terms of cardiovascular risk factors in Australians with a psychotic illness (Galletly et al., 2012; Morgan et al., 2014) and many of us have been trying to encourage patients to establish better links with GPs and to have metabolic monitoring performed more regularly (Organ et al., 2010). The proposed AUD$7.00 co-payment for GP visits and laboratory tests will undoubtedly undermine these efforts. The Government needs to hear this and to hear it very loudly. But who should be doing the shouting? To its credit, our College has been advocating for our patients in this regard, but to be truly
effective we should, in my view, do these things in conjunction with other Colleges such as that of the General Practitioners and with organisations such as the Australian Medical Association: these groups should be very nimble and, importantly, united in conveying this sort of message. They should also be involving non-government organisations with an interest in mental health as well as advocacy groups and consumers and carers. It is much more powerful having a single strong message than many smaller disparate voices, often with somewhat dissonant views. For this, we need very effective lines of communication across cognate groups in order to deliver strong clear views along with specific advice as to what needs to be done in a timely manner. Use of media should augment this, but care always needs to be taken that the message that gets through is ours rather than that of the journalists or editors interested in controversy and the sensationalism of clashing perspectives. We also need to be much more proactive about articulating what we believe in, regarding mental health service delivery. Again, I believe our College should lead this. If our professional body does not, we inadvertently perpetuate a situation where the Government turns inevitably and repeatedly to a small, select group of our colleagues who have
1Departments
of Psychiatry and Behavioural Science, The University of Melbourne, Melbourne, Australia 2Psychiatry, St Vincent’s Hospital, Melbourne, Australia Corresponding author: David J Castle, St Vincent’s Hospital Melbourne, PO Box 2900, Fitzroy, VIC 3065, Australia. Email: [email protected] DOI: 10.1177/0004867414546877
It is so refreshing to see debate being seen as a key role of the Australian and New Zealand Journal of Psychiatry. And debate not just about clinical trials and science, but more broadly about services and service delivery, education and advocacy, lobbying and politics. Allison and colleagues (2014) have taken some of these issues forward in responding to an initial piece in the Journal by Jorm and Malhi (2013) and subsequent articles by Carr and Waghorn (2013), Whiteford and colleagues (2013) and Castle (2013). The initial call was to reflect on where psychiatric services are going, in Australia. More broadly, though, there was an
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. See Viewpoint by Allison et al., 2014, 48(9): 802–804.
Reference Allison S, Nance M, Bastiampillai T et al. (2014) Health advocacy and the funding of mental health services reform. Australian and New Zealand Journal of Psychiatry 48: 802–804.
Australian & New Zealand Journal of Psychiatry, 48(9) Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on April 24, 2015
873
ANZJP Correspondence made it their business to play politics. That these individuals have been effective should be an encouragement to the rest of us that we could actually make a difference with government in a big way if only we were united and articulate and develop the right contacts on both sides of politics. To me, reliance on lobbying is a poor way to run a country, but, as Allison et al. (2014) reflect, it is the game that is being played and we simply have to be good at playing it. Some individuals amongst us are already proficient at playing this game, but for the sake of achieving broader and truly representative advocacy we require our representative bodies to take on this mantle and regard it as a core component of what they do and, indeed, stand for. And, as individuals, we need to be in lock step with them.
Funding
Allison S, Nance M, Bastiampillai T et al. (2014) Health advocacy and the funding of mental health services reform. Australian and New Zealand Journal of Psychiatry 48: 802–804. Carr VJ and Waghorn G (2013) To love and to work: The next major mental health reform goals. Australian and New Zealand Journal of Psychiatry 47: 697–698.
Castle D (2013) Where to for Australian mental health services? Promoting self-efficacy. Australian and New Zealand Journal of Psychiatry 47: 699–702. Galletly C, Foley D, Waterreus A, et al. (2012) Cardiometabolic risk factors in people with psychosis: The second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry 46: 753–761. Jorm AF and Malhi GS (2013) Evidence-based mental health services reform in Australia: Where to next? Australian and New Zealand Journal of Psychiatry 47: 693–695. Morgan V, McGrath JJ, Jablensky A, et al. (2014) Psychosis prevalence and physical, metabolic and cognitive comorbidity: data from the second Australian national survey of psychosis. Psychological Medicine 44: 2163–2176. Organ B, Nicholson E and Castle DJ (2010) Implementing a physical health strategy in a mental health service Australasian Psychiatry 18: 456–459. Whiteford H, Harris M and Diminic S (2013) Mental health service system improvement: Translating evidence into policy. Australian and New Zealand Journal of Psychiatry 47: 703–706.
Mental health advocacy and rhetoric in our time Vaughan J Carr1,2
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 selfinterest, 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 governmentfunded, the MHCA is vulnerable to the vagaries of the government of the day,
1School
of Psychiatry, University of New South Wales, Sydney, Australia 2Schizophrenia Research Institute, Sydney, Australia Corresponding author: Vaughan J Carr, UNSW Research Unit for Schizophrenia Epidemiology, O’Brien Centre, St Vincent’s Hospital, 394–404 Victoria Street, Darlinghurst, NSW 2010, Australia. Email: [email protected] DOI: 10.1177/0004867414547987
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
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. See Viewpoint by Allison et al., 2014, 48(9): 802–804.
References
Australian & New Zealand Journal of Psychiatry, 48(9)
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on April 24, 2015
ANZJP Correspondence
groups who can help open what political scientists refer to as ‘the policy window’, and are emphasising the solutions as well as the problems. What remains rare is to highlight the successes as part of this package. It is almost as if we fear that doing this will take the pressure off government to act. But if the cost of getting more funding is damage to the morale and reputation of the sector, and the staff and services we rely on to deliver treatment and care, what do we really gain for the consumer? There are too many examples of funding going up and quality of care remaining stagnant or going down. The reasons for this are complex to be sure, but a barrage
of unconstructive criticism doesn’t help. Cancer and cardiovascular services, for example, seem to get resourced with a better balance in their advocacy. As the mental health sector becomes more sophisticated, and the stigma and discrimination that surrounds mental illness lessens, we should emphasise our successes, identify the deficiencies and highlight the benefits that will accrue to consumers and their families from innovative solutions. Governments like to be associated with success, not only the hope of success and not always the compulsion to intervene in a crisis.
Funding
What should psychiatrists be doing to improve the mental health of the community? David J Castle1,2
implicit question about what we as psychiatrists should be doing to influence the course of mental health service development. Allison et al. (2014) are quite correct to take the 2014 Federal budget as something of a watershed, as it seems to have within it overt or covert challenges to many aspects of our society, not least welfare, education and health. Of course, psychiatrists should vociferously advocate for our patients in response to the proposed budget cuts in as far as they are likely to have a negative impact on people with a mental illness. Not only will there likely be fallout for our patients’ mental health but also for their physical health. For example, we are very conscious of the appalling statistics regarding unmet need in terms of cardiovascular risk factors in Australians with a psychotic illness (Galletly et al., 2012; Morgan et al., 2014) and many of us have been trying to encourage patients to establish better links with GPs and to have metabolic monitoring performed more regularly (Organ et al., 2010). The proposed AUD$7.00 co-payment for GP visits and laboratory tests will undoubtedly undermine these efforts. The Government needs to hear this and to hear it very loudly. But who should be doing the shouting? To its credit, our College has been advocating for our patients in this regard, but to be truly
effective we should, in my view, do these things in conjunction with other Colleges such as that of the General Practitioners and with organisations such as the Australian Medical Association: these groups should be very nimble and, importantly, united in conveying this sort of message. They should also be involving non-government organisations with an interest in mental health as well as advocacy groups and consumers and carers. It is much more powerful having a single strong message than many smaller disparate voices, often with somewhat dissonant views. For this, we need very effective lines of communication across cognate groups in order to deliver strong clear views along with specific advice as to what needs to be done in a timely manner. Use of media should augment this, but care always needs to be taken that the message that gets through is ours rather than that of the journalists or editors interested in controversy and the sensationalism of clashing perspectives. We also need to be much more proactive about articulating what we believe in, regarding mental health service delivery. Again, I believe our College should lead this. If our professional body does not, we inadvertently perpetuate a situation where the Government turns inevitably and repeatedly to a small, select group of our colleagues who have
1Departments
of Psychiatry and Behavioural Science, The University of Melbourne, Melbourne, Australia 2Psychiatry, St Vincent’s Hospital, Melbourne, Australia Corresponding author: David J Castle, St Vincent’s Hospital Melbourne, PO Box 2900, Fitzroy, VIC 3065, Australia. Email: [email protected] DOI: 10.1177/0004867414546877
It is so refreshing to see debate being seen as a key role of the Australian and New Zealand Journal of Psychiatry. And debate not just about clinical trials and science, but more broadly about services and service delivery, education and advocacy, lobbying and politics. Allison and colleagues (2014) have taken some of these issues forward in responding to an initial piece in the Journal by Jorm and Malhi (2013) and subsequent articles by Carr and Waghorn (2013), Whiteford and colleagues (2013) and Castle (2013). The initial call was to reflect on where psychiatric services are going, in Australia. More broadly, though, there was an
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. See Viewpoint by Allison et al., 2014, 48(9): 802–804.
Reference Allison S, Nance M, Bastiampillai T et al. (2014) Health advocacy and the funding of mental health services reform. Australian and New Zealand Journal of Psychiatry 48: 802–804.
Australian & New Zealand Journal of Psychiatry, 48(9) Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on April 24, 2015
873
ANZJP Correspondence made it their business to play politics. That these individuals have been effective should be an encouragement to the rest of us that we could actually make a difference with government in a big way if only we were united and articulate and develop the right contacts on both sides of politics. To me, reliance on lobbying is a poor way to run a country, but, as Allison et al. (2014) reflect, it is the game that is being played and we simply have to be good at playing it. Some individuals amongst us are already proficient at playing this game, but for the sake of achieving broader and truly representative advocacy we require our representative bodies to take on this mantle and regard it as a core component of what they do and, indeed, stand for. And, as individuals, we need to be in lock step with them.
Funding
Allison S, Nance M, Bastiampillai T et al. (2014) Health advocacy and the funding of mental health services reform. Australian and New Zealand Journal of Psychiatry 48: 802–804. Carr VJ and Waghorn G (2013) To love and to work: The next major mental health reform goals. Australian and New Zealand Journal of Psychiatry 47: 697–698.
Castle D (2013) Where to for Australian mental health services? Promoting self-efficacy. Australian and New Zealand Journal of Psychiatry 47: 699–702. Galletly C, Foley D, Waterreus A, et al. (2012) Cardiometabolic risk factors in people with psychosis: The second Australian national survey of psychosis. Australian and New Zealand Journal of Psychiatry 46: 753–761. Jorm AF and Malhi GS (2013) Evidence-based mental health services reform in Australia: Where to next? Australian and New Zealand Journal of Psychiatry 47: 693–695. Morgan V, McGrath JJ, Jablensky A, et al. (2014) Psychosis prevalence and physical, metabolic and cognitive comorbidity: data from the second Australian national survey of psychosis. Psychological Medicine 44: 2163–2176. Organ B, Nicholson E and Castle DJ (2010) Implementing a physical health strategy in a mental health service Australasian Psychiatry 18: 456–459. Whiteford H, Harris M and Diminic S (2013) Mental health service system improvement: Translating evidence into policy. Australian and New Zealand Journal of Psychiatry 47: 703–706.
Mental health advocacy and rhetoric in our time Vaughan J Carr1,2
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 selfinterest, 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 governmentfunded, the MHCA is vulnerable to the vagaries of the government of the day,
1School
of Psychiatry, University of New South Wales, Sydney, Australia 2Schizophrenia Research Institute, Sydney, Australia Corresponding author: Vaughan J Carr, UNSW Research Unit for Schizophrenia Epidemiology, O’Brien Centre, St Vincent’s Hospital, 394–404 Victoria Street, Darlinghurst, NSW 2010, Australia. Email: [email protected] DOI: 10.1177/0004867414547987
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
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. See Viewpoint by Allison et al., 2014, 48(9): 802–804.
References
Australian & New Zealand Journal of Psychiatry, 48(9)
Downloaded from anp.sagepub.com at NANYANG TECH UNIV LIBRARY on April 24, 2015
