What does real change in mental health mean?

We need a paradigm shift in how we think about, talk about and treat mental health in Australia. This shift requires leaders and doers at all stages of policy and implementation to be thinking and collaborating more systemically.

By Joe Sciglitano, Head of Design

This article attempts to tackle some pretty big issues. We’re gonna go on a journey into dominant mental health paradigms, systems thinking and the challenges of truly empowering people with lived experience. But fear not, dear reader, we’ll end with three ways you can start working with these challenges yourself.

It’s National Mental Health Month right now. We’re likely to see lots of posts and well-intentioned sharing aimed at helping individual citizens take better care of themselves and each other. Go for a walk. Get a good night’s sleep. Eat healthy. Talk to a friend. This is all valid and valuable advice, and perhaps if more of us took it seriously, we’d see a marked change in the rates of depression and anxiety across the country. But is it the whole picture?

Currently, government bodies, funding models and even Royal Commission recommendations are set up to tackle mental health directly, as though ‘mental health’ were a set of individual, discrete issues that can be solved with a simple intervention, in the same paradigm we think of and treat physical health. But is that really how any of us experience mental health challenges? Or are they more often tied to work, family, relationships, social systems and broader physical health issues?

A recent project we worked on with a government health body looked at the public understanding and perception of ‘mental wellbeing’ across the state of Victoria. What we learned pretty quickly is that people’s understanding of mental health isn’t limited to the categories and definitions that the caretakers of our public systems often use. The concept of mental wellbeing is as complex and nuanced as each individual Victorian. People in our community want to see systems that understand mental health as a more holistic concept. They want programs and services that embrace the interconnected roles of physical, spiritual and emotional wellbeing. They want decision-makers to acknowledge that good mental health is both a collective and individual endeavour. This is not an easy shift for us to make, but it is vital.

Addressing the bigger picture with Systems Thinking

At a recent 'Design Safari' at Portable (our fortnightly share session where we inspire each other by bringing new ideas into our team from beyond our walls), two of our Design Strategists Emily MacLoud and Adam Corcoran shared some tools on Systems Thinking; a methodology that helps us think beyond acute problems to understand the interconnected elements, relationships and forces at play.

One such tool from Adam Groves builds on the work of Systems Change pioneer Donella Meadows and gives us a framework to model the ‘leverage points’ that can be acted upon to make changes in a complex space. One variable maps the chronological status of the problem, from cause (or ‘before’) through to symptom or (‘after’). The other maps leverage points from tweaking the low-level parameters (easy to manipulate but lacking in impact) through to shifting the dominant paradigms and ultimately the goals of the system itself (which are best defined as the actual real-world outcomes achieved by a system, regardless of the intention).

What we learned from some quick analysis is that the majority of the energy and funding in complex spaces such as mental health has historically been spent addressing symptoms, rather than causes. These efforts often leverage improving existing products, services and experiences, rather than addressing more ingrained structures and ways of thinking.

And there’s good reason why: surface-level problems are more visible and apparent, as are the solutions. There’s an illusion of real change taking place because it is easier and quicker to take action. Through hundreds of briefs that cross our virtual desks at Portable across mental health, access to justice, family violence and more, I’ve yet to see a single tender, brief or RFP that explicitly asks for a systemic view of the problem. It’s not where the money is going.

Over the past decade in the mental health sector in Australia, we’re seeing a greater shift to prevention. This is a good thing, as it moves from treating symptoms to treating causes. But it’s not enough. When the broader systemic drivers and paradigms aren’t also a part of the picture, even as context, we’re only ever going to be “diddling with the details” and “arranging the deck chairs on the Titanic,” as Meadows puts it, rather than impacting the dominant, often unexamined beliefs that define our paradigms.

So how do we shift paradigms?

One such way is to realise the power of lived experience. A friend of mine is in a lived experience leadership role at a mental health organisation in the Northern Territory. She brings with her a deep intuition of how mental health issues actually show up for people that can only be understood by someone who has lived through them and is in recovery. Her voice, and others like hers, are incredibly precious in these forums. The conversations she has every day chip away, bit by bit, at outdated perceptions and beliefs and ultimately shape the interventions for people in our community. Lived experience roles in leadership were virtually non-existent a decade ago, and that’s a change worth celebrating.

But we’ve still got a long way to go in truly empowering and integrating lived experience into these organisations. My friend was recently asked to contribute some writing for the organisation’s social marketing (for National Mental Health Month). Although seemingly straightforward, the ask, and others like it, requires a great gathering of courage and energy. They require respect and a compassionate space that can hold the vulnerability of sharing some very personal challenges in a public forum.

Unfortunately, the culture and processes of the organisation do very little to support this, and in many cases, work actively against it. After labouring over her piece and submitting it to the marketing department, she was provided with a cut-down, edited version of her words that replaced some of the more honest and challenging truths within with what she described as a ‘saccharine sweetness’ that undercut the points she was trying to make. It took significant inner work, bolstered by years of experience in recovery, to overcome her initial reactions to this seemingly innocuous workplace transaction.

Once she’d processed the situation, she responded with assertion and grace, leading with empathy and vulnerability to help her colleagues understand the impact of changing her story without her consent, and to ask of them what any of us would expect: respect. It’s a struggle even to have lived experience honestly represented in marketing communications, let alone to shift the underlying paradigms driving millions of dollars of funding each year.

But these paradigm-shifting conversations are happening. They happen every day at Portable, with our team, and when there’s enough courage and trust established, with our clients too. Increasingly we’re being asked to help organisations build their capability in co-design, another important methodology that empowers lived experience as part of the problem solving process. We’ve even developed our first public training course to help push this along. There are signs of positive change everywhere. What it will take is a collective and persistent effort to constructively challenge the dominant paradigms, and present ways of thinking and doing that empower those with the responsibility to make positive change with the tools and means to take action.

Here are three ways we believe people working in mental health can be part of this shift:

  1. Deep listening to people with lived experience — starting from a place of respect and shifting the dial from consultation to co-design, right through to co-production.

  2. Challenging ourselves with a systemic view — bravely moving from treating symptoms towards conversations and experiments that sense into underlying causal structures, value systems and belief systems.

  3. Creating and testing new paradigms that challenge simplistic definitions of mental health — working with diverse experts across multiple fields to collaborate, experiment and share new models of understanding.

Does every project to improve mental health outcomes need to aspire to change the system? No, there is still important and meaningful work to be done in acting on the lower-level leverage points; working on these solutions can mean the difference between a service experience that’s designed with empathy and one that unintentionally re-traumatises people. But we need to be honest that when we approach complex problems without some effort applied to sensing and responding at the systemic level, our solutions can only succeed if they are compatible with the current system.

We’re on the cusp of a paradigm shift. There are signs of that everywhere. But we also know old paradigms die hard. So now’s not the time to relax, but to reform. And we’re here for it.

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