When I was a kid we had two great insults - "You're spastic" and "You're mental". The media has played a great part in gaining respect for people with cerebral palsy, and it's been a long time since we saw 'spastic' in a headline. But some newspapers still use words like 'psycho' and 'nutter,' killers are called 'psychotic' when the vast majority are sane, and people with mental health problems are often portrayed as intellectually inferior. If that's what the public is shown, that's what the public is going to believe.
- Liz Main, quoted in Mindshift: A Guide to Open-Minded Media Coverage on Mental Health
Every three or four years the Care Standards Improvement Partnership, a health and social care quango, commissions a survey of the public’s views and perceptions of mental illness. The results of the 2007 survey are illuminating, surprising and disturbing in equal measure. In general, it found that people are considerably less tolerant towards people who are mentally ill than they were 10-15 years ago.
Intolerant sympathy – sympathetic intolerance
In 1994, for example, 19% of people agreed with the statement “people with mental illness are a burden to society”. By 2007, this had increased to 22%. Similarly in 1994, only 8% of people agreed with the statement “people with mental illness don’t deserve our sympathy”. By 2007, 13% agreed. The number of people agreeing that “we need to adopt a far more tolerant attitude toward people with mental illness in our society” has decreased by 8 percentage points, from 92% in 1994 to 84% in 2007. There is an increasing feeling that people have reason to fear people who are mentally ill.
Over half of people mentioned that someone close to them has had some kind of mental illness, and 61% of people thought there was at least a one-in-ten chance that they would have a mental health problem at some point in their lives. They are right – it is nationally estimated that 1 in 4 people with have a mental health problem at some point on their life.
But more than a third of respondents thought that as soon as a person shows signs of mental disturbance s/he should be hospitalised ; and the number of people who think that mental hospitals are an outdated way of treating people with mental illness has decreased from 42% in 1994, to 38% in 2003, to 33% in 2007.
There is an obvious incongruity here. Nearly two thirds of people believe that they or somebody close to them will suffer from mental illness, yet more than a third of people believe that a person should be admitted into hospital as soon as a sign of mental illness manifests itself. Clearly most people do not want to be automatically admitted into hospital themselves, nor do they wish this for their friends and relatives. One must therefore assume that it is those other, dangerous people that we hear about in the media who should be locked up.
Missing the point
It is frustrating that the CSIP survey does not dig a little deeper, to try and uncover what shapes people’s attitudes to mental illness. Had it done so, it might have revealed some of the limitations of the government’s approach to mental health.
That approach is influenced by Lord Layard’s Depression Report, and seeks to increase drastically the number of short-term psychological interventions (such as Cognitive Behavioural Therapy), and to help service users engage with society, and specifically work, as quickly as possible. Any increase in psychological therapies is to be welcomed, but there are a number of problems with the government’s approach.
Firstly, the promotion of CBT appears to be at the expense of other types of therapy, despite an lack of evidence that CBT helps people with more profound neurotic disorders. Secondly, there is very little extra cash to fund the extra CBT professionals needed (since CBT enables people with mild to moderate anxiety and depression to access employment, the policy is deemed to be cost-neutral). And thirdly, the government’s policy takes CBT’s credo – that neurotic disorders are caused by damaging mediating thoughts which distort the causal links between external stimuli and emotions – at face value. The government is happy to believe that ideas cause neuroses ; they are not prepared to question what causes the ideas to form in the first place.
Why, for example, are certain people more susceptible to mental ill health than others? Why is it that people who are economically and socially excluded more vulnerable? Could it be that it is our society’s structural inequalities, and not individually-fostered ideas, which shape our mental health?
The class divide
There is substantial evidence to prove that the incidence and treatment of mental illness depends on one’s social class and race. Late capitalist societies don’t like to talk about class too much nowadays, but a bit of ferreting reveals some instructive statistics.
The National Psychiatry Survey of Great Britain 1993 shows that there is a strong correlation between under-privileged social class and limiting neurotic disorders (i.e. disorders which prevent people from carrying out basic daily activities). Unemployed people, non-home owners and those who left school before 16 – we’re talking about that considerable underclass which used to be known as the proletariat here, ok? – were between two and three times more likely to be seriously neurotically ill than those in employment, who owned their home and/or who had undergone education after 16.
Psychological surveys across Europe and the rest of the western world demonstrate similar results. The national survey carried out in the Netherlands in 1996 showed that people who left school before the age of 16 were 98% more likely to have mood or personality disorders than those who continued in education until 16 or older. The 1997 annual Australian survey showed that long-term unemployed people were up to 4 times more likely to suffer from an “affective disorder”. The 1998 Health Survey in England showed that for men the lowest quintile of household income showed incidence of neurotic disorders more than twice as the highest quintile (though, interestingly, household income seemed not to bear on neurotic illness for women). Perhaps most shockingly of all, Donald Acheson’s 1998 Inquiry into Health Inequalities showed that working class men were three times more likely than average to commit suicide.
There is much more evidence to show how one’s ethnicity might affect one’s mental health, and we would do well to remember the link between race and class. 19% of people from Pakistani and Bangladeshi households and 15% of black people rely on benefits, compared to less than 10% of white people. In 2001/02 just over 40 per cent of Bangladeshi men aged under 25 were unemployed compared with 12 per cent of young White men. People from black and minority ethnic (BME) communities are far more likely to be victims of violent crimes, and are much more likely to suffer from physical health problems.
So how do people from BME communities fare when it comes to mental health?
The David Bennett Story
In 2003, Sir John Blofeld, Chair of the Independent Inquiry into the death of David Bennett, concluded that “institutional racism is present throughout the National Health Service. This is a disgrace. Final responsibility lies fairly and squarely with the Department of Health.” The Bennett Inquiry was launched after suspicions by his family that the death of David Bennett was caused by neglect and misdiagnosis brought about by racial assumptions and attitudes.
David was African-Caribbean and schizophrenic, and had been using mental health services for many years. At first, psychiatrists did not diagnose his schizophrenia, putting his behaviour down to excessive cannabis use. 100% of staff at the Norvic Clinic in Cambridgeshire, where David was treated as an inpatient, were white, despite a significant number of black patients. His cultural needs were never addressed, no advocacy was made available, and his family were never engaged. When eventually his schizophrenia was diagnosed, he was heavily medicated almost to the point of sedation. As a result, his blood pressure flatlined.
On the night that David died in 1998, he had been in an argument with another patient. Staff at the clinic generally liked David, but knew that he could be aggressive. He had been known to attack staff without provocation. This particular argument got especially heated, with the other patient racially abusing David, and both men struck out at each other. David was medicated and moved to another ward. When he asked why it was he who had to move, he received no explanation. Later a nurse told David that he was to stay on the new ward indefinitely. David hit the nurse and was physically restrained by a number of nurses. He was taken to the floor and placed in a face down position. During the prolonged struggle he collapsed and died.
David Bennett’s case is an extreme within a continuum. Black African and Caribbean men are ten times more likely to be diagnosed as schizophrenic as white men (though, as we have seen, misdiagnosis is as problematic as non-diagnosis), and three times more likely to be hospitalised for mental health problems. They are 44% more likely to be detained under the Mental Health Act and twice as likely to be brought into services by the police or the courts. Once in hospital Black men are 50% more likely to be secluded and 29% more likely to have been subject to physical control or restraint than white men.
It has been claimed that mental health care is akin to custodial sentencing for black men. The police are involved in many mental health referrals, not just those involving section 136 of the Mental Health Act 1983 which allows them to arrest disturbed people in public places. Research has shown that the police are inconsistent in their use of this section and detain a higher proportion of Black people under it.
Yet the Department of Health disagreed with Sir John’s conclusion, denying that institutional racism exists in the NHS. The phrase “institutional racism” does not, of course, mean that racism is perpetrated actively or deliberately. But in a society where racism, both overt and covert, deliberate and mechanical, thrives, it is inevitable that most public institutions will be racist. There is a case for claiming that the medical profession might be especially so.
Psychology is dominated by educated, middle-class professionals. Middle class people, however liberal, have a barely-repressed fear of working class people. There is a general feeling that the lower classes have not quite acquired the finishing touches that befit civilised humans ; they are, in short, loose canons. (This may be why many left-leaning liberals are so petrified of the idea of revolution – in case the wrong type of person gets control of the system.)
If anything, this applies even more to black people. In a report for Open Mind in 1997, Melba Wilson wrote that 'when the dimension of race is added to the media portrayal of people suffering from mental distress, the notions of big, black and dangerous (male and bad and black) become fused in public perceptions.'
The charitable consortium Open Up has done valuable work exploring how the media traces an ominous line between race, mental illness and violent crime, and has reported how in 1994 the Daily Express published an article entitled 'Care in crisis as mental patients are freed to kill'. The article used one word under each picture of a person who had committed a murder. The white faces were accompanied by words like 'graduate' and 'released', whereas the black faces had 'violent' or 'stabbing' written beneath them.
It is impossible for any of us to think about each other without pigeon-holing. The fact that a person is black, or working-class, or gay, or female will open a pandora's box of assumptions. Unless we attack these, no amount of CBT is going to cure the world of its neuroses and psychoses. The only way to do this is to combat poverty and inequality.
During the 1980s and early 1990s, there was precious little focus on the NHS, and especially not on its most cindarella-ish of corners, mental health. The present government has been guilty of pandering to the right-wing press, but it has also, to an extent, invested more in mental health services and promoted their importance. But under Labour, poverty and inequality have increased exponentially, just as they have during the last three decades, that period of neoliberalism. Unless the very roots of our economic and social structures are shaken, the most vulnerable and stigmatised sections of our society will continue to be deprived of the services they need.