Editorial

Editorial

Article Type: Editorial From: Mental Health and Social Inclusion, Volume 20, Issue 1.

Rachel Perkins and Julie Repper

"Parity of esteem" for mental health services or parity of life chances for those experiencing mental health challenges?

The explicit ambition of the 2011 Cross-Government Mental Health Strategy was "to mainstream mental health, and establish parity of esteem between services for people with mental and physical health problems" (Department of Health, 2011, p. 1).

This message seems to have gained considerable traction and been augmented by a "call to action" by NHS England and a more in depth consideration by the Royal College of Psychiatrists.

The call is for a recognition of mental illness on a par with physical illness and an end to the situation where mental health problems account for 28 per cent of morbidity yet receive only 13 per cent of NHS expenditure (NHS England, 2014). And the campaign is spreading. More recently, in the lead up to the Government Spending Review in 2015, public figures – including Norman Lamb, Mary Beard, Danny Boyle, Alastair Campbell, Bob Geldoff, Miranda Hart, Sam Allardyce and the archbishop of Canterbury – came together with in an open letter open letter to Government demanding equality for mental health[1]. This petition, signed by 19,825 people to date asks for:

[…] the same right to timely access to evidence-based treatment as is enjoyed by those with physical health problems. We accept, and urge ministers to accept, that this will require additional investment in mental health services (Equality for Mental Health, 2015, p. 1).

Who could object to parity of esteem for mental health and more money for psychiatric services? Of course it is important that people receive timely, high-quality treatment and services. However, we would like to raise a note of caution.

Although passing reference can be found to decreasing the discrimination experienced by people facing mental health challenges, the focus is firmly on parity of esteem for mental health services rather than people experiencing mental health challenges. The open letter calling for equality for mental health raises ten key concerns (Equality for Mental Health, 2015):

• people with mental health problems do not enjoy the same access to services and treatment as those with physical health problems;

• until April 2015 there were no maximum waiting times for mental ill-health – more funding will be required to make the new waiting time targets a reality;

• financial incentives discriminate against mental health: whenever resources are under pressure mental health services lose out;

• too many mentally ill people are shunted around the country in search of a bed;

• too few people who lose their jobs are having the mental health impact of unemployment taken into account so lack the treatment that might help them get a job;

• too many children and adults in mental health crisis are still ending up in police cells rather than hospital;

• too many people with mental ill-health are inappropriately in prison;

• people with long-term mental health conditions live, on average, 20 years less than the general population;

• people from certain ethnic groups (especially African-Caribbean and African) over-represented in acute mental health services and secure services: more frequently experience use of coercion and physical restraint and have less access to talking therapies; and

• vital research to gain a better understanding of mental illness and establish the most effective treatments is compromised by lack of funding relative to research relating to physical illness.

Yes, all of these are important. But is better access to more effective treatment going to be the most important thing in improving the lives of, and creating equality of life chances of people facing mental health challenges?

Despite all the remaining problems and shortcomings, within the ten years of the Mental Health National Service Framework (Department for Health, 1999) there was greatly increased access to treatment and therapy, and a focus on early detection and treatment, with developments including Early Intervention Services, Assertive Outreach Services, Crisis and Home Treatment Services and Psychological Therapy in Primary Care. Yet at the same time, people with mental health conditions remain more socially isolated and more likely to be living alone than people living with other health conditions and impairments and more likely to be the victims of disability-related harassment and hate crime. More than one-third lack stable and appropriate accommodation; unemployment rates have increased and remain far higher than those of people living with other health conditions and impairments; and the proportion claiming incapacity benefits has risen (see Office for Disability Issues, 2013; Department of Health, 2013; Sayce, 2015).

Clearly, reducing distress through effective and timely treatment and intervention is important. But at the bottom line, better access to treatment and therapy have not resulted in better lives or life chances for many people facing mental health challenges. We need to think beyond treatment and services. Lack of treatment is frequently not the only, or even the biggest, barrier facing people living with mental health challenges.

People diagnosed with mental health conditions remain the most excluded in our society and media images of "mad axe murderers", "poor unfortunates who need to be looked after" and "social security scroungers" continue to reinforce and perpetuate the prejudice and stereotypes that underpin the discrimination that so limit life chances. Although evaluation of the UK "Time to Change" anti-stigma campaign has found a moderate, positive impact on attitudes relating to prejudice and discrimination it appears that the campaign has been most effective in disconfirming negative ideas about exclusion rather than enhancing positive attitudes about the right to live a full and active life in the community (Evans-Lacko et al., 2014). It remains the case that the proportion of people with mental health challenges who report experiencing no discrimination has not changed: in 2008, 91 per cent reported experiencing discrimination in at least one area of life and, although there was a slight improvement in 2011 to 88 per cent by 2012 it was back to 91 per cent (Henderson et al., 2014 – see Sayce, 2015 for fuller analysis of attitude data).

The language of establishing parity between physical health and mental health tends to reinforce the message that "mental illness is an illness like any other": "[…] we should make no distinction between illnesses of the brain and illnesses of other body systems" (cited in Royal College of Psychiatrists, 2013, p. 20). This has been the core message of many anti-stigma’ campaigns and in the UK "Attitudes to Mental Illness Survey" agreeing with the statement "mental illness is an illness like any other" is taken to indicate positive, non-discriminatory attitudes (TNS BMRB, 2015). Indeed, this measure of "positive" attitudes has improved over the years: in 1994 71 per cent believed that "mental illness is an illness like any other", 20 years later – in 2014 – this had risen to 78 per cent.

The assumption is that if mental disorders are seen as illnesses – attributed to factors outside the person’s control – then reactions to people with such disorders will be less negative. However, this assumption is not backed up by research data – quite the opposite is the case. Although holding "illness" – biomedical – explanations of mental distress increases the likelihood that people will seek treatment it also increases negative stereotypes, prejudice and discrimination. If people think that mental illness is an illness they are more likely to see the person as dangerous and unpredictable, more likely to fear the person and more likely to desire social distance from the person – avoid them. Moreover, desire for social distance from the person’s relatives is also increased, especially close contact like dating, marrying and having children (see, e.g. Sayce, 2000, 2015; Phelan, 2005; Read et al., 2006; Pescosolido et al., 2010). If it implies parity between mental and physical illness, the "parity of esteem" messages may actually exacerbate the discrimination and exclusion experienced by people living with mental health challenges.

The "parity of esteem" focus on services tends to reinforce the assumption that more and better treatment=more and better mental health. This ignores the social determinants of mental, and indeed physical, health. Marmot (2015) provides a wealth of data demonstrating conclusively that health spend is not the primary determinant of the health of populations. Differences in health – both physical and mental – result from social disadvantage: relative social disadvantage results in health disadvantage and shorter lives. The loneliness, exclusion, lack of control over your life that result from relative disadvantage are more important determinants of health.

In the introduction to his book, Marmot (2015) describes an experience as a medical student:

The woman looked the very picture of misery. Her gait almost apologetic, she approached the doctor and sat down, huddling into the chair […] "Oh doctor," said the patient, "my husband is drinking again and beating me, my son is back in prison, my teenage daughter is pregnant, and I cry most days, have no energy, difficulty sleeping, I feel life is not worth living." […] The psychiatrist told the woman to stop taking the blue pills and try these red pills. He wrote out an appointment for a month’s time and, still a picture of misery, she was gone. That’s it? No more? To incredulous medical students he explained that there was very little else he could do. The idea that she was suffering from red-pill deficiency was not compelling. It seems startlingly obvious that her depression was related to her life circumstances […] "We" should be paying more attention to the causes of her depression. The question of who "we" should be, and what we should do, explains why I discarded my flirtation with psychiatry and pursued a career researching the social causes of ill-health and […] advocating action (Marmot, 2015, pp. 1-2).

What really makes a difference is not access to technical treatment or exhorting people to lead healthier life-styles but creating the conditions in which people can flourish in their lives. Empowerment is the key to improving health, yet reference to empowerment, social exclusion, isolation, poverty, unemployment, deprivation of liberty are absent from the Equality for Mental Health (2015) open letter and receive only passing reference in most documents on parity of esteem.

Interestingly, when the Equality for Mental Health (2015) open letter was reported in the guardian, several of the "comments" posted in response made a similar point[2]:

As someone who has severe depression, I’d like to see more mental health services available, I’d like to see more access to psychological services. I’d like to see more even distribution of wealth. I’d like to see less focus on competitiveness in schools, because intense competition against each other makes our society less happy. I’d like to see a greater focus on community in our towns and cities, a sense that we are part of a community rather than isolated individuals. I’d like to see a less single-minded focus on the economy as being the indicator of a country’s progress, and more focus on our wellbeing. I’d like to see a better work-life balance (currently the UK works 15% more hours than France or Germany). I’d like to see a greater focus on tackling the social issues that may be behind ill health rather than tackling the physical symptoms (talking therapy rather than medication). I’d like to see more people realise that increasing their social ties, their sense of belonging in the world, and the health of their family relationships will do a lot to improve their wellbeing (dynamicfrog, 2 November 2015 9:31).

There is also a much deeper problem in how government (and governments in general) treats so called "mental health". "Mental ill health" is not necessarily a disease or illness in people, which would occur anyway, or just occurs randomly. The knowledge we have now tells us that if any person is subjected to forms of oppression and adversity, that they will suffer adverse consequences, to their "mental health" (STeB1, 2 November 2015 7:00).

A focus on parity of services to create "equality for mental health" may promote equality of services, but does not create equality of mental health or equality of opportunity for those who experience mental health challenges to flourish in their lives. Focusing solely on treatment, therapy and services as the route to "equality for mental health" detracts attention from the social determinants of health and health inequalities and risk diverting resources from social initiatives to increase empowerment and life chances (e.g. employment support services, an initiatives to reduce social exclusion, promote community participation and enable people to pursue their aspirations) to increase the availability of therapy and treatment.

We know that poor housing, social isolation, unemployment, abuse, poverty and the lack of control that accompany them, cause mental health problems and increase the likelihood of relapse of those who experience mental health challenges. We also know that it is possible to act to change these. In the pages of MHSI we have published many innovative accounts of empowerment and ways of increasing opportunity, and would welcome more contributions.

Maybe we should focus not on parity of esteem between physical and mental health services, but equal rights for the people living with mental health challenges who use those services. Not simply rights to treatment, but rights to participate in all facets of economic, social, family and civic life and rights to the support and adjustments that make participation possible […] and thus reduce the loneliness, exclusion and disempowerment that both cause mental health problems and decrease the life chances of those who experience them.

www.equality4mentalhealth.uk/

www.theguardian.com/society/2015/nov/02/public-figures-sign-letter-seeking-equality-mental-health

References

Department for Health (1999), National Service Framework for Mental Health. Modern Standards & Service Models, Department of Health, London

Department of Health (2011), No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages, Department of Health, London

Department of Health (2013), No Health Without Mental Health: Mental Health Dashboard, Department of Health, London

Equality for Mental Health (2015), "Open letter to government", available at: www.equality4mentalhealth.uk/ (accessed 8 January 2016)

Evans-Lacko, S., Corker, E., Williams, P., Henderson, C. and Thornicroft, G. (2014), "Effect of time to change anti-stigma campaign on trends in mental illness-related public stigma among the english population 2003-13: an analysis of survey data", The Lancet, Vol. 1 No. 2, pp. 121-8

Henderson, C., Corker, E., Hamilton, S., Williams, P., Pinfold, V., Rose, D., Webber, M., Evans-Lacko, S. and Thornicroft, G. (2014), "Viewpoint survey of mental health service users’ experiences of discrimination in england 2008-2012", Social Psychiatry and Psychiatric Epidemiology, Vol. 49 No. 10, pp. 1599-608

Marmot, M. (2015), The Health Gap. The Challenge of an Unequal World, Bloomsbury, London

NHS England (2014), "A call to action: achieving parity of esteem; transformative ideas for commissioners", NHS England, London

Office for Disability Issues (2013), Fulfilling Potential. Building a Deeper Understanding of Disability in the UK Today, Department for Work and Pensions, London

Pescosolido, B.A., Martin, J.K., Long, J.S., Medina, T.R., Phelan, J.C. and Link, B.G. (2010), "‘A disease like any other’? A decade of change in public reactions to schizophrenia, depression and alcohol dependence", American Journal of Psychiatry, Vol. 167 No. 11, pp. 1321-30

Phelan, J.C. (2005), "Geneticization of deviant behaviour and the consequences for stigma: the case for mental illness", Journal of Health and Social Behavior, Vol. 46 No. 4, pp. 307-22

Read, J., Haslam, N., Sayce, L. and Davies, E. (2006), "Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach", Acta Psychiatrica Scandanavica, Vol. 114 No. 5, pp. 303-18

Royal College of Psychiatrists (2013), "Whole-person care: from rhetoric to reality. Achieving parity between mental and physical health", Occasional Paper No. OP88, Royal College of Psychiatrists, London

Sayce, L. (2000), From Psychiatric Patient to Citizen. Overcoming Discrimination and Social Exclusion, MacMillan, Basingstoke

Sayce, L. (2015), From Psychiatric Patient to Citizen Revisited, Palgrave Macmillan, London

TNS BMRB (2015), "Attitudes to mental illness 2014 research report. Time to change", TNS BMRB, London