“The expertise gained from lived experience should be complemented by professional expertise, not overwhelmed by it. All stand to benefit from ensuring that there are as few imbalances as possible in the distribution of power throughout the mental health system”
By Howard Chodos, Ph.D.
Before I began working on health and mental health policy just over a decade ago, I was trying to earn my living (not very successfully) as an academically trained political theorist. In the course of my work, I had thought a lot about the nature of power and how it is exercised. Now, after having been a lead author on the three major Canadian documents on mental health policy, I am glad to have the chance to draw on both parts of my training and experience to contribute to your discussion.
There are many ways for power to be exercised improperly, just as there are many ways for it to be exercised properly. In the context of mental health, I would suggest that there at least four “levels” at which it is important to understand the dynamics of power:
- The relationships that are established between providers and users of services;
- The ways mental health (and other interconnected) systems are structured and organized;
- The ways in which disparities influence people’s opportunities in life;
- The legal and policy frameworks that shape activity in all things relating to mental health.
I want to review briefly the approach taken in the Mental Health Strategy of Canada – Changing Directions, Changing Lives (CDCL, 2012) – to each of these dimensions. The launch of CDCL last May marked a significant milestone in Canadian health and social policy. For over a decade stakeholders had advocated for such a strategy. I am pleased to note that to date the response to it has been overwhelmingly positive. But as we stress in the Strategy itself, implementing its recommendations (including those that touch on redressing imbalances of power) is a job for all of us.
“Beyond government, it is clear that workplaces, non-governmental organizations, the media, and many others all have a role to play” (pp. 12 CDCL).
The Framework
The foundations of the approach to the dynamics of power in the Strategy were developed in the Framework document, Towards Recovery and Well-Being, which we released in late 2009. In it, we stressed the importance of acknowledging the damage that can be caused by power imbalances and, given this, the importance for everyone to think about their own work:
[…there is a] need for people of all origins to think critically about their own approach to mental health and mental illness, and to seek ways to address the power imbalances and inequities that can have a major impact on health and social outcomes.
We also placed an orientation towards recovery at the heart of the vision for change. The principles underpinning a recovery orientation were seen to be relevant to the full range of policy proposals and to all people:
To varying degrees, the principles that inform a recovery orientation – such as fostering hope, enabling choice, encouraging responsibility, and promoting dignity and respect – can, and must, apply to people of all ages…
Finally, we argued for the equal treatment of people living with mental health problems and illnesses and their right to participate fully in all aspects of Canadian life:
People of all ages living with mental health problems and illnesses [must be] accorded the same respect, rights, and entitlements and have the same opportunities as people dealing with physical illnesses and as other people living in Canada.
So how are these principles reflected in the recommendations of CDCL across the four “levels” identified above? Here are a few brief examples.
1. Relationships and rights
The Strategy insists on the need for all providers of mental health services to have access to training and education in recovery-oriented practices so that “everyone [can] learn how to build true partnerships”. Perhaps more importantly still, the Strategy repeatedly emphasizes the critical importance of involving people living with mental health problems and illnesses not only in making decisions about the direction of their own journey of recovery but also at every level of the mental health system. Redressing imbalances of power will require that the voices of people are heard, and their ability to advocate for themselves is supported.
The Strategy seeks to ensure that people can exercise meaningful choice in selecting the treatment, service or support that will best meet their individual needs. For example, it advocates exploring the benefits of “self-directed care” initiatives in which people are given control of resources that allow them to select from a wide range of possible services or supports. At the same time, the Strategy recognizes the reality that there are times when decisions will have to be made on behalf of people whose illness has undermined their independent capacity, while calling for stringent safeguards to be in place to protect people’s rights even during crisis situations.
2. System Structure and Institutional Practice
When almost all mental health “care” was delivered in large stand-alone, psychiatric facilities a person was often “forced” into an institution through the exercise of the power of the “system” itself. We have come a long way, but have still not managed to develop the right balance between community-based and institutional care to meet the full range of people’s needs, as and when they arise. To address this, the Strategy recommends increasing investment in community mental health services.
Changes are also needed at the level of individual institutions. The Strategy calls for always using the least restrictive and least intrusive means, and of curtailing the use of practices such as seclusion and restraint. In order for these practices to become virtually unnecessary, “recovery-oriented and trauma-informed alternatives” will need to be deployed.
3. Disparities
Not everyone benefits from the same opportunities in life. While disparities in opportunity (arising, for e.g., from lack of income) may not always be the result of the direct exercise of power by any given group or individual, they can still exert a powerful influence on mental health and well-being. Addressing such complex social disparities requires the combined effort of many people. One of the measures recommended in the Strategy is to deploy a “mental health equity lens” to all policy to assess its impact on overcoming these disparities so that “everyone benefits and … the gap decreases between those who are best and least well off.”
“The expertise gained from lived experience should be complemented by professional expertise, not overwhelmed by it. All stand to benefit from ensuring that there are as few imbalances as possible in the distribution of power throughout the mental health system” (pp. 35 CDCL)
4. Policy and Legal Frameworks
The Strategy states clearly that “consistently upholding the rights of people living with mental health problems and illnesses is an integral part of fostering recovery and well-being.” It embraces the UN Convention on the Rights of Persons with Disabilities and calls for legislation across the country to be reviewed and updated where necessary to align with the Convention. In particular, the Strategy endorses the UN Convention’s “social” approach to disability that understands disability to arise not from a person’s individual condition itself but from a person’s interaction with the physical and social environment.
The Strategy recommends that other types of policy also be reviewed to ensure that they adequately meet the needs of people living with mental health problems and illnesses. For example, it recommends that any financial disincentives in income support policies that might hinder people from returning to work or pursuing their education be removed. In order to help eliminate all forms of discrimination against people living with mental health problems and illnesses the Strategy makes many recommendations that reach beyond the health and mental health systems. These include the need for better access to safe, secure and affordable housing as well as better support for people who are seeking to return to work or pursue their education.
As even a quick overview such as this indicates, there are many dimensions of “power” that need to be addressed if we are to have a mental health system, and a society, that enables “all people in Canada [to] have the opportunity to achieve the best possible mental health and well-being.” I believe that the Mental Health Strategy for Canada provides a solid foundation upon which to begin and sustain a conversation on how best to accomplish this in every corner and region of the country and points to many specific ways for overcoming the barriers that stand in the way.
The Mental Health Strategy for Canada is not a strategy only for governments and bureaucrats (although it is that as well). It is a strategy that depends on everyone becoming engaged in the discussion and looking for ways to bring its many recommendations to life in their own communities, workplaces and throughout their encounters with the mental health system. We look forward to working with people across the country to help make this happen.
Howard Chodos, Ph.D., has been with the Mental Health Commission of Canada since its inception and now serves as Special Advisor, Mental Health Strategy for Canada.
