Anti-discrimination actions in mental health.

Abstract

Professionals in mental health should practice a non-discriminatory approach to care. Few would disagree with this statement, acknowledging exceptions where positive discrimination is appropriate and also that unconscious ‘discriminatory’ practices can and do occur. Professional codes of practice and mental health policy guidance documents emphasize the policy of valuing diversity, of providing culturally sensitive services, of challenging psychiatric stigma and of creating a care provision culture that is supportive and respectful. The philosophy and policy framework is in place but are actions on the ground delivering a non-discriminatory service? A series of recent reports would suggest that mental health is seriously challenged by discriminatory practices both in terms of racism within psychiatry but also considering discrimination in a broader civil rights framework. The term ‘discrimination’ is defined in civil rights law as the unfavourable or unfair treatment of a person or group of persons in comparison to others on the grounds of, for example, race, sex, colour, religion, age, disability or sexual orientation. Since the Stephen Lawrence inquiry the term ‘institutional racism’ and thus institutional discrimination has been widely discussed where systems and practices rather than individuals are responsible for reform agenda. To move forward both the ‘system’ and the individuals within it must together address poor levels of cultural awareness, including race, gender and mental health awareness, and structural discriminatory practices. Within psychiatry the challenge is to provide services that promote equity, equality and effectiveness whilst planning needs led services that respect the rights and values of each mental health service user. Across statutory and voluntary sector mental health services the picture on the ground will be mixed with examples of non-discriminatory approaches to care emerging. Service users and carers acknowledge the benefits of these approaches, but inequalities in service provision ensure that access to best practices is varied. The recent inquiry report into the death of David ‘Rocky’ Bennett and the Inside Outside report from the Department of Health focuses attention on the treatment of black and ethnic minority clients within the mental health system. The Bennett inquiry, launched March 2003, has made 22 recommendations. It acknowledges that institutional racism is prominent in mental health services, and calls for all who work in mental health to receive training in cultural competency, awareness and sensitivity. The Bennett report, as well as highlighting race issues, should also ensure that safety in hospitals for all psychiatric patients receives increased scrutiny. Inequalities in rates of mental illness, use of the Mental Health Act between different ethnic groups and a shortage of interpreter services in the UK is well documented. Black and minority ethnic (BME) service users are also known to have, in general, overwhelmingly negative experiences of psychiatry (Sainsbury Centre for Mental Health 2002). As a consequence, these communities are not seeking help to prevent or manage their mental health. More research is needed in this area but central to these investigations will be solutions for tackling racist actions both within and beyond psychiatry. A number of pragmatic proposals combining community development, service user empowerment and a public health approach have been suggested. Psychiatric stigma and discrimination are worldwide public health concerns hindering individual mental health help-seeking behaviour and inhibiting recovery pathways. The impact of psychiatric stigma and discrimination is most commonly measured in public attitude surveys, with the latest UK public attitudes to mental illness survey 2003 showing reduced public tolerance, and employment statistics providing an indicator of social exclusion. The impact on individual lives – both carer and service user – has led to anti-discrimination campaigns being set up across the globe, often targeting the media and young people with information resources and education workshops delivered with experts by experience (see http://www.openthedoors.com and http://www.mindout.net). The mental health system has a part to play in both perpetuating psychiatric stigma or discrimination and eradicating it. The Royal College of Psychiatrists recent Changing Minds Campaign has reviewed stigma and discrimination within the medical profession (Council Report CR91, 2001). It made a number of recommendations including training that addresses the attitudes of doctors and improves communication and listening skills. It emphasizes that: ‘within the context of a diagnostic approach to illness, respect be preserved for the uniqueness, dignity and rights of the individual . . . diagnostic labelling must not be at the expense of recognition of and respect for the uniqueness of the individual’. Solutions to the dominating climate of fear, ignorance and prejudice surrounding mental health and mental illness require reforms to both psychiatry and changes in wider society. The multilevel, multifaceted approach advocated by leading academics ( Link & Phelan 2001, Sayce 2003) is currently being pioneered in New Zealand (http://www.likeminds.govt.nz) and Scotland (http://www.seemescotland.org), with education programmes led by service users operating alongside a framework for litigation – the stick and the carrot approach. Unfortunately the UK government for England and Wales have not provided the same commitment for mental health promotion or anti-discrimination programmes. Furthermore, the proposed mental health bill provides campaigners with serious concerns that levels of stigma within the mental health system will actually increase in the future. Discrimination on the grounds of gender or sexuality in mental health settings must also be addressed. Research calls for mental health services to be more responsive to women's needs, building on the progress that has been made in recent years to develop capacity and expertise across mainstream services. Women-only and women-sensitive services are required (Barnes et al. 2002), such as Mann Saffer for Asian women in Middlesex where women feel better supported because help is relevant to their experiences of mental distress. Gay, lesbian and bisexual service users can face the same discrimination within mental health services as they do in wider society. Research has found higher levels of suicide contemplation and history of attempted suicide in gay men and lesbians when compared with heterosexuals or bisexuals linked to intimidation. Greater levels of psychological distress have also been recorded and training for professionals to ensure awareness of mental health issues for among gay men and lesbians is being recommended (King 2003). Staff within health and social care settings are also the victims of discriminatory practices. The Commission for Heath Improvement (CHI) staff survey reveals levels of physical violence across the NHS at 15% usually from patients or relatives and 37% staff have experiences bullying, harassment or abuse at work (see http://www.chi.nhs.uk/surveys/), and these figures are generally higher in mental health provider trusts. For example, one North London trust reported 25% staff experiencing physical violence in previous 12 months and 54% experiencing harassment, bullying or abuse. A proportion of these incidents will be based on discriminatory actions such as staff being racially abused by patients. Concerns over the treatment of BME staff in the NHS have also been highlighted recently by the Royal College of Nursing survey (see http://www.rcn.org.uk/publications/). Rethink severe mental illness recently carried out a large survey to record the service user experience of mental health services. Rethink received 3005 responses and the information has been summarized in a series of reports (see http://www.rethink.org/reseach/). The importance of a non-discriminatory approach to care was a key theme. What helped respondents during first experiences of mental health problems? The most frequently reported factors were documented as being able to talk about problems, the caring and kind attitudes of staff, being believed and understood, being treated by competent professionals, people who were positive and reassuring, being treated with respect. When service users reported a positive experience from first contact with mental health professionals it was because staff were empathetic, friendly, kind and considerate. The survey also asked service users to rank changes needed to improve mental health services. ‘Less discrimination in the work place’ was ranked in the ‘top three’ priorities for 46%, and 29% wanted more public education to reduce stigma. Recommendations from the survey stressed that service users should have a legal right to care and treatment, be recognized as experts by experience and be listened to, involved and represented in service planning. In a similar survey with 1500 carers in 2003, Rethink found that family members and friends recognized that standards in mental health care were improving for both service users and carers but significant challenges remained particularly over recognizing the contribution made by family and friends to community mental health care. What helps carers is timely information, specific support services, being involved and consulted by health and social care professionals and access in emergencies to necessary help and support. Carers who feel ignored by professionals experience worse adverse affects on their mental health physical health, their family relationships and leisure activities. In the Rethink sample, 67% of carers felt valued by mental health staff for their skills and 55% felt their opinions are taken into account always or most of the time. The launch of the new Mental Health Media ‘open up’ web resource (http://www.openuptoolkit.net) underscores the importance of non-discriminatory approaches in mental health. It supports individual service users or service user groups to combat discrimination in mental health (http://www.openuptoolkit.net), although it will be useful for anyone promoting social inclusion and mental health. The ‘know your rights’ section outlines how to stand up against unfair treatment. The site also encourages people to take action and also to come together to share ideas and experiences. The National Institute of Mental Health England (NIMHE) is also encouraging the sharing of ‘good practice’ by commissioning a number of tool kits (http://www.nimhe.org.uk). What works to reduce discrimination in mental health care? The published evidence base is this area is weak but practice based knowledge is far stronger. Successful local practices must also be shared and key to finding solutions are mental health service users. A review evaluating ‘what works’ to reduce stigma and discrimination has also been commissioned by NIMHE with a summary available through the website. Non-discriminatory approaches to care which include valuing diversity, of working in a culture that is supportive and respectful, offering services within a framework for challenging stigma and discrimination are unlikely to be delivered throughout the mental health system without a programme of both increased financial investment and reform. Part of the reform will require increased levels of user and carer involvement in shaping services and developing models for understanding mental illness. Professional training should include modules designed and delivered by service users and carers, including those from BME communities. Anti-discrimination campaigns should place these experts by experience at the centre of activities seeking to dispel stigma and improve public mental health literacy. Training is at the centre of these recommendations; in order to develop appropriate and effective learning modules health professionals must work alongside service users and carers to develop training materials based on reflective practice.