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Strengthening community understanding


The way that we as a community often shun people who live with a mental health difficulty72 erodes their quality of life. Everyone has the right to be treated without discrimination, but for people experiencing mental illness, being ignored, talked down to, or treated ‘differently’ is a lived reality in everyday interactions.73

Ending discrimination about mental illness starts with individuals, families, schools, workplaces and communities.

Strengthening community understanding helps build peoples’ capacity to identify and better understand the early signs of mental distress. But understanding is not enough by itself – it must be used to help improve lives on an everyday basis. It must be used to help us change our behaviour from a tendency to withdraw and ignore towards a tendency to reach out and support.

We can provide inclusive environments where people with a mental health difficulty and their families will feel more confident about not encountering discrimination – and to call it when they do – and so access the services and supports they need.

Communities that are diverse are stronger when people have an understanding of each other.74 Strong communities contribute to our wellbeing. These benefits are undermined when we feel excluded from participating and when there is little acceptance of diversity. New Data iconAll too often people with mental health difficulties experience this, and frequently raise stigmatising attitudes as their greatest concern.11 This experience of stigma and discrimination also affects their families and support people.

This chapter will focus upon how our understanding of mental health issues affects how we treat or discriminate against people living with a mental health difficulty and their family or support people. It will look at how well our communities understand mental health, and what the consequences of poor understanding are for us as a community and for the lived experiences of people with a mental health difficulty to lead a contributing life.

Under the Australian Disability Discrimination Act 1992, discrimination is defined as the treatment of (or proposal to treat) another person less favourably on the basis of their disability when compared to other people. This can be intended or unintended, and this law applies to how ‘people with a psychiatric disability’ are treated as well as their families and support people.75

We will look closely at discrimination at the broader community and institutional scale, as well at the micro-scale of individual interactions.


What we know

In just about every sphere of life – making friends, living next door to or working closely with someone, falling in love – we know entrenched discriminatory attitudes exist. Too many of us still hold discriminatory and prejudiced views about mental illness and towards people who live with schizophrenia.55, 76

The 2011 National Survey of Mental Health Literacy and Stigma76 found that:

  • just under half (45.1 per cent) of people surveyed indicated they would not want a person with schizophrenia marrying into their family and around a quarter (28.2 per cent) would not want someone with depression marrying into their family;
  • between 32.6 per cent and 48.6 per cent of people would avoid someone with a mental health difficulty – from avoiding people with Post Traumatic Stress Disorder (PTSD) to those with chronic schizophrenia;
  • 37 per cent of people would not employ a person with chronic schizophrenia and 23.4 per cent would not employ someone with depression.

It is unacceptable that people who live with the most disabling mental illness also face the most discrimination and misunderstanding, as Figure 3 shows.

Figure 3: Attitudes to employing someone with varying mental health disorders

Reported desire to keep a social distance from people with selected mental illnesses


Attitudes to socialising have not shifted over the last eight years, as shown in Figure 4. We know that such discrimination can play out in the small and daily interactions between people. These micro-inequities, where minor instances of discrimination or inequality are experienced repeatedly, build up to compound a person’s experience of discrimination.77 These experiences can even be felt coming from those who are supposed to be providing help.78

Life Buoys Icon

This surely contributes to the fact that 65 per cent of the estimated 3.2 million Australians who have experienced a mental health problem in the past 12 months have not sought help.49

In one survey, 61.4 per cent of carers reported feeling that the health professionals treating the person they supported did not really understand what it meant to have a mental illness, while 31.3 per cent had seen the person they cared for shunned by health professionals when it was revealed they had a mental illness.78

National and international research shows that discriminatory behaviours compound self-stigma, discouraging people from participating fully in treatment, with negative impacts upon their recovery and health.78 They also withdraw from daily activities.55, 76

Figure 4: Reported desire to keep a social distance from people with selected mental illnesses

Figure 4: Reported desire to keep a social distance from people with selected mental illnesses bar chart

New Data iconThe early findings of the Commission’s own pilot online survey found that 23.3 per cent of respondents said that social discrimination ‘got in the way’ of them feeling connected to family, friends, culture or community.11 

We also know that discrimination associated with mental illness extends to families79 and can affect their own behaviour.80 Misunderstandings of a family’s role or responsibility can lead to negative attitudes from health professionals which make family members feel discounted or ignored,81 and can inform how people outside the family react.82

In one survey of support people:

10.6 percent of support people reported being treated often or very often as less competent by others when they learned they were a mental health carer. 30 percent avoided telling people outside their immediate circles that they were a mental health carer. about 60 percent of respondents had experienced negative, hurtful and offensive attitudes from the public.

Discrimination and bullying – for example at work, or because of sexual orientation or race – contribute to poor mental health.83 We know that young people who are bullied are at-risk of higher rates of poor mental and physical health and suicidal behaviour, which can carry over into adulthood.84 In Queensland, of 63 youth suicides in 2011/12, at least three were directly attributable to bullying.85 

We know that the Australian media continues to play a powerful and influential role in shaping and changing attitudes through informed reporting.86-89


Experience of discrimination among Aboriginal and Torres Strait Islander peoples

Experience of discrimination is culturally variable

Social and emotional wellbeing and the impacts of racism

Aboriginal and Torres Strait Islander peoples describe their mental health as having a foundation of ‘social and emotional wellbeing’ originating in a network of relationships including those between the individual and their community traditional lands, family and kin, ancestors and the spiritual dimension of existence.90 Life is understood in holistic terms: with the health of individuals and communities evident not simply by the absence of disease but linked to their ‘control over their physical environment, of dignity, of community self-esteem, and of justice.’91 Respect for Aboriginal and Torres Strait Islander rights is fundamental to social and emotional wellbeing: racism and discrimination are associated with negative physical and mental health impacts.92

The approach of ‘social and emotional wellbeing’ provides a less stigmatising description of mental health than the western culture’s views, based as they are on formal psychiatric/medical definitions and concepts.

For Aboriginal and Torres Strait Islander peoples living with a mental health condition, a ‘matrix of discrimination’ (reflecting compounding and cumulative experiences of racial discrimination and stigmatising attitudes towards their mental health condition) can be particularly challenging. In practice, it may not be possible for such a person to identify precisely why they have been discriminated against, in any given situation.

Likewise, it will not be necessarily possible to separate out the existence of a mental health condition from the experience of racial discrimination. Almost without exception, international studies find that racism and racial discrimination are associated with poorer mental health status93, 94 – findings echoed in the eight studies on the impact of racism on Aboriginal and Torres Strait Islander peoples that have occurred to date.95-102

When discussing the stigma faced by Aboriginal and Torres Strait Islander peoples with mental health conditions, it is important that forms of discrimination are not viewed in isolation and that any effort to address stigma on the grounds of mental health acknowledges and incorporates Aboriginal and Torres Strait Islander people’s lived experience of racial discrimination.


Experience of discrimination among Culturally and Linguistically Diverse (CALD) communities

Cultural attitudes and understanding

The diversity of peoples’ beliefs, understanding and response to mental illness is shaped by their cultural heritage and experience. While a refugee’s mental health may be affected by their experience of trauma in reaching Australia, their understanding of ‘mental health’ and that of their family and community will also reflect their heritage.103 There is a broad diversity of understanding regarding the causes, expression and outlook for different illnesses. The Western model of mental ill-health is often felt to be inappropriate by many people and does not speak to their experience, which may be influenced by a combination of social, religious, biological, psychological and cultural explanations.104

There is some evidence that there can be high levels of stigmatising attitudes in some CALD communities, as there can be in all communities. Some understandings of mental illness do link it to shame, humiliation and ‘loss of face’. People from these diverse communities may have a different experience of mental illness,105 be less likely to disclose symptoms, more likely to express distress in the form of physical symptoms,106 and less likely to seek treatment which they may feel is inappropriate.107

This is compounded by limited availability of inclusive services which can provide culturally sensitive interventions, services and interpreters.103 Young refugees, adolescents in particular, are more likely to seek help from friends than from professionals because of stigma associated with mental health problems. A study of West African women living in Western Australia showed their feelings of shame or fear of being judged by others hindered their willingness to access health care services.108


What the evidence shows is good practice

The evidence we have is inconsistent in quality and therefore in the reliability of conclusions drawn.

However, national and international studies suggest that longer term anti-stigma and discrimination initiatives have more success in reducing the experience of discrimination by people living with a mental health difficulty than short-term initiatives.109

The main focus of investment in Australia since 1992 has been on broad mental health education and community understanding programs. Such programs may be successful for many people and have increased overall mental health literacy, but more targeted programs are needed for people who come into frequent contact with people with mental health problems, such as health professionals, police and workers in the justice system.

This is where Mental Health First Aid (MHFA), a training course based on person-toperson mental health education, has been effective in improving mental health literacy and reducing stigma all over the world. MHFA was developed in Australia in 2001110 and teaches people (18 years and over) how to provide initial support to adults who are developing a mental illness or experiencing a mental health crisis. There is also a course for adults working or living with adolescents. Tick icon

With its evidence of effectiveness supported by high quality evaluations and global uptake, this is an example of international best practice. For example, it has been found to be effective in workplaces and with CALD communities.111

"We work with people negotiating their gender, sexuality and/or intersex status and have developed education and training programs aimed to provide clear messages about stigma and discrimination, and the impact these have on a person’s sense of wellbeing."

Susan Ditter, Working It Out Tasmania

Only a relatively small number of initiatives have been evaluated. Evaluations of effective programs for Aboriginal and Torres Strait Islander peoples, as well as people from CALD communities, is complicated by the differences in understanding of mental illness between cultures and in the social acceptability of reporting symptoms.104 And again, there may be good practice models in operation, but these have not been evaluated.

Policies for reducing bullying have been developed for schools and workplaces. Identifying where good practice lies may be in bringing together key elements – having involved adults at school, open discussion with established boundaries on acceptable behaviours, having leadership, clear bullying policies and expectations for behaviour that are implemented.112

"Public awareness of mental health needs to increase. At the moment I feel like it is a taboo subject in the community and it needs to be able to be talked about more.”11


What we don’t know

Where we need more evidence, and to shine a light

Mental health promotion and awareness programs have been rolled out across our country. Spending by states and territories on these programs alone came to $16.4 million in 2010-2011,113 with grants to non-government organisations totalling an extra $19.65 million.15

Despite this, the Commission is concerned that we have insufficient evidence to ensure that money is being spent in the most effective way. Some examples of gaps in our knowledge are as follows.

Studies of whole-of-community, anti-stigma interventions in Australia are of insufficient quality and number to allow conclusions about effectiveness to be drawn about what works. There is also inconclusive evidence about schoolbased and tertiary educationbased campaigns in improving mental health literacy of students.

We need to have a better understanding of why improvements in overall community understanding of mental health do not translate into equal levels of improvement in reducing discrimination and stigma. We need to know why stigmatising attitudes and prejudice persist. To support this, we need to address our gaps in knowledge about why certain groups in our community hold more discriminatory views and attitudes, and what types of approaches are most effective in changing this.

"A person's identity and sense of belonging are critical to building resilience and being a participating member of the community."

Susan Ditter , Working It Out Tasmania

We do not fully understand the social and cultural factors that underlie stigma, or the ways in which it can be reduced and prevented.114 Further investigation is needed to identify how stigmatising attitudes arise and why they persist, and to generate evidence about what works to reverse them. There are many people who experience discrimination even without having mental illness. For those people – including refugees, people affected by drugs, different ethnic groups, people identifying as lesbian, gay, bisexual, transgender or intersex (LGBTI), homeless people, cognitively impaired people, and physically disabled people – developing a mental illness can exacerbate or even be a result of the experience of discrimination.

"In any community you get out of it what you put into it. Being in the community itself, the word community doesn't exist if you don't work with it and get involved with people.”11


Where the Commission is looking for continuous improvement

We know that improvements in community understanding have not been paralleled by a reduction in discriminatory behaviour and attitudes.72 The Commission looks to ways to push ahead in improving those areas most impervious to change.

We therefore call for a sustained national strategy for reducing discrimination. This needs to be multi-faceted and deployed at the community level. It needs to feature evaluation from day one. It should target groups we know remain resistant to improvement, who are in frequent contact with people with mental health problems and their supporters, and where we can make the biggest impact on attitudes and behaviour.

The benefits that can be gained from a sustained reduction in discrimination are measurable – and we look to national indicators to do this. There is a potential return on investment from this approach that needs to be universally acknowledged. The benefits will accrue on the personal level, at the family and community level, and across our nation in workplaces and schools.

The Commission looks for improvement in specific areas:

As stigma from health professionals is an area of significant concern to people living with a mental health difficulty and their support people, we need to tackle this as a priority.

There is also a clear need for approaches to address mental health literacy and stigma in Aboriginal and Torres Strait Islander communities. These must be culturally appropriate and developed and driven by Aboriginal and Torres Strait Islander peoples, to reflect their culture, history and social approaches to mental health and wellbeing.

We must also not forget the need for improved mental health understanding across CALD communities, and for cultural diversity to be reflected in practice.

Research shows that discriminatory attitudes vary with particular mental health conditions. Further work should address mental health literacy and stigma reduction, particularly in relation to schizophrenia. Some of the most discriminatory attitudes are directed at people living with this illness, yet it is one of the least prevalent mental health conditions. Similarly, we must continue to challenge some persisting misconceptions about the more common mental illnesses, such as anxiety disorders and depression.

In all efforts to reduce discrimination, we must incorporate the voices of people with experience of mental health problems and their families and support people. Their expert feedback can help to create more responsive and higher quality services and can be especially powerful to drive attitude change.

In a human service organisation, the lived experience of people with mental illness and their families and support people is directly affected by the skills, attitudes and behaviour of staff. Staff who have clear objectives and well-structured appraisals are more likely to report they are engaged in the work of their organisations than those who do not. Engaged staff are those who are well led, with the leaders of frontline teams having a particularly important role in creating a climate for changing attitudes.

We will not make a difference to peoples’ lives unless we are all prepared to stand up against discrimination wherever we may witness it.

The Commission believes it is time to positively discriminate in favour of people living with a mental health difficulty. We believe that just improving understanding of mental health issues in the community is insufficient. It is only by starting with our everyday interactions, within our families, schools and workplaces, that we can foster behaviours which are inclusive. If people feel more included, they are more likely to seek help when it is most effective.

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