I was recently asked to address a conference and was allocated the topic “A lawyer’s perspective on challenging stigma within the system.” This got me thinking.
Stigma is real for most people suffering from mental disorders but what do we mean by stigma? The dictionary defines it as “A strong feeling of disapproval that most people in a society have about something especially when this is unfair.”
STIGMA CREATES DISADVANTAGE
Society has stereotyped views about mental illness and how it affects people. The media would have us believe that the mentally ill are violent and dangerous, when in fact they are more at risk of being attacked or harming themselves than harming other people.
Stigma and discrimination can worsen mental health problems and delay or impede getting help, treatment and recovery. This exacerbates social isolation, poor housing, unemployment and poverty. Stigma and discrimination can trap people in a cycle of illness.
However when did you last see a care plan that addressed the issue of stigma and how to combat it? The mental health system rarely addresses it indeed, I would argue, it contributes to it. But what has this got to do with advocates. Read on.
THE EXTENT OF DISADVANTAGE CAN BE SHOCKING
A study by researchers at University College and Kings College London, published in September 2014 in Psychological Medicine, reports that of women with severe mental illness surveyed for the study, 40% had been the victims of rape or attempted rape. This compares with 7% of the general population (the figures for men are no less remarkable, although lower overall: 12% of men with severe mental illness had been seriously sexually assaulted, versus 0.5% in the general population).
“The reality for patients is that they are at increased risk of being victims of some of the most damaging types of violence.” Professor Louise Howard, Kings College London
Somebody seriously sexually abuses nearly one in every two women with severe mental illness. Although this is an association rather than a proof of causation the study makes it clear that the illnesses being treated could not all be caused by the abuse as all participating patients had been treated for at least a year and 10% had experienced sexual assault within the past year at the time of the survey.
So it looks that for at least some (and perhaps most) of the victims, the assault would not have happened if they had not been suffering from mental illness.
FORGET STIGMA LETS CALL IT WHAT IT IS – DISCRIMINATION
As I think that we would all acknowledge, the discrimination associated with mental illness is tangible. So surely we would expect to see advocates raising this from the perspective of the service user, rehabilitation plans acknowledging the likely discrimination that people will suffer and then assist with developing coping mechanisms as to the best way to counter this. Care, treatment and rehabilitation plans should surely include assistance for people in combating what they will surely experience.
BUT WILL NOT THE LAW PROVIDE PROTECTION?
The UN panel on the Convention on the Rights of Persons with Disabilities recently criticised the UK for its failure to uphold disabled people’s rights. Article 12 is about “Equal recognition before the law”
The areas of concern by the committee contained over 60 recommendations for the UK government. The government was dismissive. Indeed last November the same UN committee issued a scathing report on austerity policies in welfare and social care, which it described as “systematic violations” of the rights of people with disabilities. The government dismissed that report as “patronising and offensive”.
SURELY OUR LAW PROVIDES SOME PROTECTION?
Under the Equality Act 2010 it is illegal to discriminate directly or indirectly against people with mental health problems in public services and functions, access to premises, work, education, associations and transport. The Equality Act 2010, on the face of it, gives the right to challenge discrimination but a mental health condition is considered a disability only if it lasts, or is likely to last 12 months and has a long-term effect on normal day-to-day activity. It is up to the person alleging discrimination to prove that.
Public authorities have an additional duty to eliminate discrimination and promote equality of opportunity, called the “public sector equality duty”. Perhaps you might have seen evidence of this in combating mental health discrimination, I have not.
THE FARCE CALLED SAFEGUARDING
I would suggest that this has become institutionalised, wastes money and is not about protecting vulnerable people in any meaningful way. Perhaps I will write another paper about this.
THE DISSAPOINTMENT OF THE CARE ACT
You might think that placing the person’s wellbeing at the centre of the process would ensure that systemic anti stigma mechanisms would be built in and these would be encouraged (where they are involved) by Care Act advocates. Need I say more?
HOW DO WE COMBAT INSTITUTIONISED STIGMA?
Not only should we be including within care and treatment plans ways to help people recognise and combat this, but there is very little evidence in my experience that we may any attempts to promote autonomy.
Making lawful best interests decisions in relation to those who are not able to understand consequences is an important part of protection. However, how many best interests’ decisions demonstrate evidence that the second principle has been complied with. Without this any best interests decision is unlawful.
In addition, the MHA Code chapter 9. “Wishes expressed in advance”
These are statements by patients about preferences for what they would, or would not, like to happen if particular situations arise in future. When did you last see one of these? When did an advocate have a conversation with a service user about using them to promote empowerment and autonomy?
The Code tells us that “Advance statements and decisions strengthen patients’ participation in their treatment and recovery and help them to feel more empowered about what may happen to them should they lack mental capacity to make decisions about their care and treatment in the future.”
For those who lack capacity to make certain key decisions there is a tendency to make them safe even if it makes them miserable. “What good is it making someone safer if it merely makes them miserable? “(Sir James Munby Re MM (An Adult) ) It might be useful if local authorities kept a telly on how many people, for whom they made best interests decisions, they made miserable each week?
THE WORST EXAMPLES OF INSTITUTIONALISED DISCRIMINATION
Leaving acutely mentally ill people deteriorating in the community, at increasing risk from others, leaving them exposed to the vulnerably created by their illness exposes them to greater stigma. The fundamental cause is lack of beds but actually people forget that a person is detainable under the MHA if it is in the interests of their health caused by the nature of their condition. How many areas of medicine are there where in effect a person is told to go away until they get worse!
With buzz words like safeguarding, rehabilitation, recovery and wellbeing meaning very little for many, those supporting, advocating and treating people with a mental illness must not ignore the discrimination that service users experience through stigma.
Stigma equates with discrimination and this leads to disadvantage and we must focus on how to reflect these experiences into treatment plans?
If you think that the law will help combat this. Forget it. The fight against this should starts much closer to home.