Mental Health Awareness Week 2008
6-12 October
Make your mark for mental health
Ko te tutukitanga, ka totoro, ka kawe kee, ka whakatau te manawanui
ABOUT THE AUTHOR
Ruth Gerzon is passionate about advocacy, human rights and social inclusion and
community development. She has developed and facilitates training packages on health
promotion and advocacy, and on social inclusion in the fields of mental health and
disability. She lives in the Eastern bay of Plenty where she chairs a mental
health/disability service working towards inclusion for all.
She was executive officer for the Serious Fun ‘N Mind Trust, (BOP Like Minds, Like Mine
Project) (1999-2003). She has also worked as an advocate, teacher (primary and
tertiary), journalist and produced books and videos on rights and inclusion in the
intellectual disability field.
Her qualifications are: M.Phil (Social Policy, Massey 2003), Dip Tchng (Waikato Uni
1981) and Cert Journalism (Wellington Polytechnic 1971).
She would welcome comments and critique of this article from readers interested in
advancing social inclusion. She can be reached at ruthgerzon@gmail.com.
Social Inclusion
By Ruth Gerzon
Social inclusion has become widely acknowledged as vital to mental wellbeing yet its
exact nature is often unexamined, and mental health services do little to support people
to overcome their isolation and exclusion.
People without close family ties leave hospitals for residential services, then graduate to
‘independent living’. This move may be heralded a success, but in reality people in flats
and boarding houses are often lonely. Unable to make the transition from roles as
passive patients to active roles in communities, they have little sense of purpose or
belonging. Isolated and marginalized, many become unwell again, re-entering acute
care.
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Communities are sometimes the problem. In spite of the Like Minds, Like Mine project,
they are far from being giant shopping malls of great experiences awaiting intrepid
explorers. Yet our community mental health services also need to change if social
inclusion is to become a reality.
Most services still focus on what is wrong with people. Someone entering a mental
health service may have decades of success as a parent, worker, volunteer or
sportsperson. All this is discarded when they walk through a hospital door to become a
‘patient’. Their skills and achievements are not noted on their files, nor form a basis for
connection with the people they encounter in this new world. Welcome to a new life as a
passive recipient of care, where your past is all but irrelevant.
This world is underpinned by unequal relationships. Staff are paid to meet your needs;
your only role is as ‘patient’. For short periods we all need this level of support, but for
some people entering mental health services this new world and their new role becomes
their life, one they may never leave behind.
In this world a whole bunch of rules apply. ‘Patients’, ‘residents’, ‘clients’ or ‘service
users’ learn not to have expectations about privacy, individuality or confidentiality. They
learn about conformity, compliance and dependency.
Dr Patricia Deegan has noted that, “becoming a ‘good’ mental patient often means
learning to become preoccupied with matters pertaining to ‘me’….Socialization into meness, self-preoccupation and being a consumer means that many people are denied the
opportunity to discover they have something to offer to other people.”1
Recovery stories show that self-preoccupation is not healthy. Both contribution to others
lives and mutual relationships are vital ingredients in recovery. People need to feel
again the basic goodness of life and gain self-respect to make progress towards mental
health.
Yet, as Davidson et al note (2001)2, most ‘community based’ services still require
people to succeed before they are ‘let in’ and continue to focus on illness, ignoring
people’s gifts and capacities.
As soon as people leave hospital for community care, the real world, the inclusive world
needs to regain its central place in their lives. In this world people have something to
offer. Everyone plays active roles, contributing to communities through paid and
voluntary work, as part of sports clubs or arts. These roles bring a sense of purpose and
belonging and full citizenship.
People’s illness impacts on their self-esteem, so they often cannot re-connect with
communities where stigma is still rife, without support. Services need to change and
support people to take these essential steps to wellbeing.
1
Deegan, Patricia, 2003, http://www.patdeegan.com/blog/archives/000015.php (22.8.08)
Davidson L, Stayner D A, Styron T H, Nickou, C, (Spring 2001) “Simply to be let in”: inclusion as a basis for
recovery Psychiatric Rehabilition Journal, Boston in MHC (2001) Book of Collected Articles: a companion to
the Mental Health Recovery Competencies Teaching Resource Kit
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The first change needs to be in their fundamental orientation. If their only relationship is
with service users they will continue to keep people dependent.
services
service users
passive recipients of care
To enable people to gain citizenship through active roles in their communities of choice
there needs to be another focus:
communities
contribution
citizenship
mutual
relationships
passive recipients of care
services
service users
Re-oriented to this third dimension, services will explore communities and deepen their
knowledge of their functions. They will find that there is no one ‘community’, but diverse
ones, in many shapes, sizes and dimensions. These may be based on ethnicity, on
shared experiences, identities, beliefs, interests, neighbourhoods or the internet. We all
feel more welcome in some communities than others: no one is comfortable in all
contexts. Many of us play active roles in two or more.
Maori communities – whanau and hapu – are based on mutual support. This gives them
strength. Seeking similar support systems, settler communities of migrants far from their
extended families, set up a multitude of voluntary associations so people new to a town
could make connections. The essential building blocks of all these communities are
reciprocal, equal relationships, where people help one another, the very opposite of
relationships on which services are based. Such mutual relationships engender three
elements essential to mental health: a sense of belonging, a sense of purpose and selfrespect.
Contrast this understanding of contribution and relationships in diverse communities with
some ‘community participation’ or ‘meaningful activity’ programmes. Their narrow focus
often resembles ‘community tourism’. Like tourists, people are encouraged to use banks
and shops, beaches and parks. These are places of commerce and relaxation, not of
connection. In these places people cannot contribute their gifts, nor build the mutual
relationships that underpin rich social networks.
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‘Social capital’ is a term often used for the mutual relationships and trust that underpin
communities. Social theorist, Robert Putnam3 sees social capital as benefitting people
in two ways.
The first is ‘bonding’, which is crucial for just getting by, for making sure there will be
someone there for us when times get tough. Without this, when we need support, we
fall back on services. Sadly some people with mental illness have become so
disconnected from families and communities that the only people in their lives are those
paid to be there.
‘Bonding’ social capital is evident in extended families, ethnic organizations, netball
teams and, within the mental health field, in some peer support groups. Peer support
groups that focus on mutual support and reject the mainstream medical model of
relationships based on helper’ and ‘helped’, can rebuild self-esteem and pave the way
for people to take up mutual relationships in their wider communities.
The second form of social capital Putnam termed ‘bridging’. Where bonding helps us
get by, bridging social capital helps us get ahead, finding work, linking us to resources
and providing information. Many of us have found work or somewhere to live through
our networks. Service clubs are a good example of bridging social capital.
Both forms of social capital are important for people with experience of mental illness.
Bonding enables people to find support beyond services. Bridging enables them to find
new valued roles and to access resources.
Over the past three decades some sociologists have noted a weakening of social
capital. Club membership is declining, sports coaches are hard to find and young
people are less active in communities than their elders. Unlike our grandparents we
often buy in support services once provided by neighbours: lawn mowing, child or elder
care. Putnam attributes some of this decline in social capital to increased viewing of
television, making us passive and individualist and encouraging materialism.
Yet there are signs of new neighbourhood initiatives, such as restoration of wetlands and
collective actions to reduce violence. Perhaps the increased use of buses and car
pooling will enable us to connect while commuting. Climate change may even have a
positive effect on social capital, as communities came together during the war years.
If Putnam is right the decline in social capital is outside the control of mental health
services. Of more concern is the view of John McKnight4, who sees services
themselves as the culprits. He believes the professionalization of care (elder care, child
care, health care) is directly responsible for reducing communities’ capacity for looking
after their own.
Reflecting on McKnight’s thesis, a colleague, Hine Tihi, noted how community support
for people with a disability weakened in a small town after a kaupapa Maori service was
3
Putnam, Robert J, (2000) Bowling Alone: The Collapse and Revival of American Community, Simon and
Schuster Paperbacks, New York
4
McKnight, John (1995). The Careless Society: Community and Its Counterfeits. United States: Basic
Books.
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set up. Before the service opened, when someone in the wharekai needed help,
everyone would chip in. Afterwards some whanau began to respond with “your
caregiver is over there…”. As professional carers move in the community backs off.
In the Like Minds, Like Mine advertisements featuring Aubrey Quinn, we see him
supported by his rich social networks. Is the need for such advertisements caused not
only by stigma but also by the professionalisation of care that leaves us keen to back off
from friends when the going gets tough, and refer them instead to social services? We
need to be mindful of the inherent contradiction between our insistence on a well trained
workforce and the central message of the Like Minds, Like Mine advertisements.
If social inclusion is vital to mental health, how can mental health services re-connect
isolated people to their communities of choice?
Existing services can turn to the model developed by supported employment. These
services help people use their gifts and capacities to find work. Sadly supported
employment is still not widely available and only deals with one aspect of people’s lives:
paid work. People with good mental health are connected to their communities through
many channels.
I believe everyone has strengths and gifts, everyone can contribute to their communities.
This is the basis on which people can be supported to gain valued roles. Real progress
on inclusion will happen when these gifts and strengths are given more prominence than
symptoms of illness.
Staff need to know how communities function and reciprocal relationships form, they
need the skills to support people to use their strengths in community settings, while
taking care to reduce the likelihood of rejection due to stigma.
We cannot ensure people have friends but we can put them in a situation in which
‘bonding’ develops, enabling them to spend time in valued roles, in communities. These
roles can be in paid or voluntary work, on marae, and in towns, as club members, in
political or environmental activities, through crafts or art.
If we are serious about social inclusion some aspects of our current services that might
need to change are:
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Training: Do staff know how communities function? Do they have the skills to
help people build reciprocal relationships? Do we need to re-orient training to
focus on practical aspects of inclusion?
Recruitment: Do we value people’s community networks and take them into
account?
Information: Do we gather information on community networks and
organisations?
Rosters: Do staff have one-to-one time? Supporting people to contribute to
communities and build relationships doesn’t happen in groups.
Job descriptions and titles: Do these still focus on ‘support’? Might staff be
called ‘community connectors’?
When setting up or funding new services: Are we sure services are part of the
solution not part of the problem?
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From their own experiences readers will see other aspects of services that might need to
change to focus on social inclusion. Change will be far reaching, mostly uncharted and
exciting. . It will need innovative and courageous leaders who believe all people can
contribute to communities and build the mutual relationships that bring good mental
health.
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