About awarenessAwareness is about developing an understanding of one's mental health needs and the potential to be vulnerable to further episodes of mental illness. Such awareness increases the likelihood people with mental illness, their families, and the services they are in contact with, will engage in health promoting and illness preventing actions.
Awareness is a developmental process. It does not necessarily occur after a first episode of mental illness, nor require a diagnostic label. Awareness is a complex and individual learning process that involves a growing understanding of the self and the place of mental illness within the self-identity. Awareness is a paradox of acknowledging potential vulnerability to future illness, while maximising mental health and not being constrained by a mental illness sick role.
Awareness is strongly influenced by attitudes toward mental illness in the community and in services. It is also affected by a wide range of social and cultural factors that impact on self-awareness and self-identity. Stigma and lack of understanding of mental health and mental illness are major barriers to awareness.
Awareness comprises a general understanding of one's mental health, but also more specific knowledge of risk and protective factors for mental health. The section Risk and protective factors for mental health below presents some of the major risk and protective factors that affect ongoing wellbeing for people who have experienced mental illness. Learning to understand personal wellness needs in terms of these risk and protective factors is essential to supporting future mental health.
At an even more specific level is the need to understand early warning signs of illness. There are common early warning signs for the major mental illnesses that are well documented.8 However, early warning signs can also be very individual and change over time. Most people are able to learn to recognise their early warning signs, although for some people this takes time to develop, and for others lack of insight persists. Support to develop awareness can be provided through psycho-education, peer support, and the help of others such as family and carers who can learn to read the early warning signs and communicate this knowledge to the person who is not able to do so.
People take time to develop awareness, and some people may take a considerable period of time to do so. This can be challenging for families and carers, as well as for service providers. Lack of awareness can be due to incomplete or inappropriate treatment, whereby continuing symptoms interfere with the development of awareness, and this may require change to a more effective treatment approach. Some people are reluctant to develop awareness as a result of a range of personal, social and cultural barriers, and the use of motivational interviewing may be helpful to understand and overcome these barriers. For other people, the denial of awareness is an important coping mechanism at that time, which is a choice that needs to be respected when it is not harmful.
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For young people, the process of awareness is complicated by their life-stage in terms of the development of self-identity and the imprecision of diagnosis for younger age groups. Special care needs to be taken to encourage young people to be aware of their vulnerability to future illness so that they undertake protective health and lifestyle behaviours, while not limiting their potential for growth. Peer support and psycho-education embedded within a strengths-based model are worthwhile approaches.
We have little understanding of the role and impact of awareness of mental illness for Aboriginal and Torres Strait Islander peoples, for whom construction of the sense of self is complex, incorporating the family and extended clan group alongside an elaborate set of relational bonds and reciprocal obligations. It may also incorporate a profound sense of continuity through Aboriginal Law, spirituality and Dreaming. Western notions of mental illness do not always apply, and it is unknown how awareness of having a mental illness and of being at increased risk of future episodes manifests for Aboriginal and Torres Strait Islander peoples. Better understanding of cultural processes and interpretations of mental health and mental illness are vital first steps in achieving culturally safe practice.
There are additional barriers for people from many culturally and linguistically diverse backgrounds regarding awareness, where the stigma of mental illness and impact on families can be heightened. Communities and local services need support to develop and implement culturally appropriate ways to educate community members about mental health and mental illness and thereby reduce stigma and increase understanding of mental health issues. Increasing community-based support and providing culturally-appropriate psycho-education are priorities for raising awareness. Underpinning this is the need to better understand identity processes and interpretations of mental health and mental illness in diverse cultural and linguistic groups.
The stigma of mental illness is also heightened in rural and remote communities, where it can be difficult to maintain privacy for individuals and families. Rural and remote communities are disadvantaged regarding access to peer support, which is an essential resource to develop awareness, and special effort needs to be made to provide access to this support. Outreach activities from the urban-based consumer and carer organisations, as well as the use of internet and other communication technologies, can be especially helpful to overcome distance barriers.
People with co-morbidities can be doubly burdened with stigma, particularly those with co-morbid substance use problems or developmental, cognitive or physical disabilities. Co-existing disorders can mask or complicate awareness of vulnerability to further episodes of mental illness. Support to develop an appropriate level of understanding of mental health issues is required for all concerned, including the person who has experienced mental illness, their family and carers, and service providers.
Risk and protective factors for mental health
- Risk factor - poor physical health
- Protective factor - physical wellbeing: general health, nutrition, sleep, exercise
- Risk factor - insecure, inappropriate and unsafe accommodation
- Protective factor - secure, appropriate and safe accommodation
Physical and emotional
- Risk factor - exposure to physical and emotional violence and threat of violence
- Protective factor - physical and emotional security
Alcohol and substance use
- Risk factor - harmful alcohol, tobacco and other drug use
- Protective factor - no harmful alcohol, tobacco and drug use
Meaningful daily activities
- Risk factor - lack of meaningful daily activities
- Protective factor - meaningful daily activities (employment, education, volunteer work, hobbies)
Life purpose and meaning
- Risk factor - lack of purpose and meaning in life
- Protective factor - sense of purpose and meaning in life
- Risk factor - lack of control over one's life
- Protective factor - sense of control and efficacy
- Risk factor - financial hardship
- Protective factor - financial security
- Risk factor - exposure to environmental stressors (eg, legal proceedings, imprisonment)
- Protective factor - lack of exposure to environmental stressors & good coping skills
- Risk factor - ineffective use of medication
- Protective factor - effective use of medication (when required)
OutcomesTo implement the Awareness component of the 4As Framework, the following outcomes need to be achieved:
- People who have been seriously affected by mental illness are able to develop awareness in their own way and their own time and through developmentally and culturally appropriate processes.
- Families and carers are able to develop awareness in a way that supports their family member and through developmentally and culturally appropriate processes.
- Services support the development of awareness for people who have experienced mental illness and their families and carers, in developmentally and culturally appropriate ways.
- Communities provide supportive environments for the development of awareness for people who have been seriously affected by mental illness and their families and carers, and the community in general.