Radical Psychology
2007, Volume Six, Issue 1



Inequality In Mental Health:
The Relevance of Current Research and Understanding To Potentially Effective Social Work Responses


Shulamit Ramon

 

Introduction


Inequality in mental health and illness is a long standing issue in mental health research, initially raised by sociologists and later taken up by epidemiologists too. Sociologists proposing to look at inequality as an issue in this field were divided in their views as to whether people become poor because they are mentally ill and thus unable to function (social selection) or they become mentally ill because of being poor (social causation). Although most sociologists today tend to favour social causation, the distinction between social selection and social causation continues to be reflected today in the dominance of genetic and biochemical explanations within psychiatry vs. the belief of sociologists and social workers that the social context acts as a major etiological determinant, though it is not the only such factor. The belief in either social selection or social causation is important since it guides us in terms of policies, methods of interventions, the message given to the person experiencing mental distress and illness, her family, friends, and society. Current interest in social inclusion (Sayce, 2000, Repper and Perkins, 2003) is rooted in Durkheim’s focus on the damage caused by social anomie (Durkheim, 1897), a version of social causation, not less than in governmental wish to reduce the number of people living on benefits.


The interest of many sociologists in mental illness has largely moved on from inequality to a discourse on power and control (Busfield, 2000), shifting more recently to the implications of modern approaches to risk for people experiencing mental illness. Nicholas Rose’s recent work (2000) illustrates well this shift in which what leads to experiencing mental illness and to recovering from it is put to one side in favour of seeing the mentally ill as one of the groups whose image depends on social fears of risk.


Conceptual approaches


a. Current Epidemiology


Instead of sociologists, epidemiologists have become the professional group most occupied with collecting the evidence concerning inequality and interpreting it. They see themselves as scientists responsible for mapping illness and health in large populations, through the application of reliable methods to the collection of valid data, analysed through parametric statistical packages.


Data on mental ill health and health is thus collected from different settings (e.g. households surveys, the census, populations living in institutions). Variables on which data is collected include age, diagnosis, ethnicity, gender, education, employment, income, housing, living arrangement, personal status, social networks, frequency and length of hospitalisation, intervention methods, criminal justice history, and physical ill health. Epidemiologists would see these as objective variables; and have paid little attention to subjective and inter-subjective variables and their indicators.


This is based on the assumption that the variables listed above may reflect risk factors related to having and maintaining a mental illness. It is rare for epidemiologists i n mental health to come up with their own explanatory framework; most mental health epidemiologists have trained as psychiatrists first, and are based in departments o f psychiatry or public health. This is in contrast to the work of some leading general health epidemiologists who are ready to accept the primacy of social factors in healt h (e.g. Muntaner, 2000, Krieger, 2005, Wilkinson, 2005); the latter illustrate a revived trend within a globalised approach to epidemiology of health.


A current debate which highlights the core of the conceptual framework -- or lack of it -- is the on-going discussion as to whether social class, income or poverty are the more relevant factors underlying inequality in mental health. Informed by US findings that income is a more discerning variable than social class (derived from a mixture of education, employment, income, housing, and parental background information) in terms of inequality, UK leading epidemiologists express their readiness to discard social class too as a major variable. The explanatory framework itself reads as a list of social variables overarched by biological ones, as Table 1 illustrates.


Table One

  

Table 1: Diagram of the potential influences on prevalence rates of the common mental disorders.

Source: Melzer, D et al. (2004), ”Social Inequalities and the Distribution of the Common Mental Disorders”, Psychology Press Ltd


The specific factors perceived as impacting on mental ill health (physical illness, stressful life events, lack of supportive social networks, work circumstances) are described as contributing factors to one’s social position, while the latter is seen as both contributing to mental illness and impacted by it. Thus the framework does not look at issues such as poverty, stigma and discrimination due to age, ethnicity and gender, in preference of individualised psychosocial experiences which may be the result of these issues. While a number of these specific factors are usually perceived as part of the experience of poverty (Bywaters and McLeod, 1996) the concept of poverty is not focused upon in the writings of epidemiologists in mental health.   Likewise, although victimisation, personal attacks, and racial discrimination are specifically mentioned as risk factors for common mental disorders in ethnic minority groups (Meltzer et al, 2004, p. 207) they are left out of the more comprehensive framework, presumably because they can be subsumed under the “stressful life events” category, even if the latter is thus rendered meaningless of a central and irreducible risk factor.


Table Two

Table 2: Risk factors for common mental disorders in ethnic minority groups

Source: Melzer, D et al. (2004), ”Social Inequalities and the Distribution of the Common Mental Disorders”, Psychology Press Ltd


The experience of either poverty or discrimination should be treated as a necessary but insufficient explanation of mental illness, as they do not explain why a specific person responds to these states of being with a mental illness.


A number of the eminent psychiatrists-epidemiologists are also known for being protagonists for relatively progressive social policies in mental health, thus the exclusion of poverty and discrimination does not necessarily indicate an adherence to a particular conservative ideology. It is more likely to reflect being trained to believe that a list of factors passes as an explanatory framework, and that the more specific and descriptive a factor is, the more scientific it is assumed to be.


The current conceptual framework used by epidemiologist in psychiatry does not explain much, especially not in terms of what leads to experiencing and maintaining a mental illness, and why agreed policies in this field are less likely to be budgeted and implemented by government than policies related to heart disease, even though the social magnitude of mental illness and heart disease is similar (Moser, 2001).


b. Current sociology


Sociological research on mental illness invariably touches on the issue of inequality in mental illness (Busfield, 2000). Historically, Goffman (1961) and Scheff (1975) looked at processes of institutionalising mental illness and of how people came to be defined as mentally ill, rather than at the traditional set of inequalities in mental health. This has marked the introduction of a very different conceptual and methodological framework from the epidemiological framework.


Brown and Harris’ (1978) researched the social and emotional isolation of clinically depressed women who are single parents, identifying these types of isolation and having three children below the age of 14 as the main reasons for their depression.  Dohrewend and Dohrenwend (1981) have focused on life events as the major trigger of mental ill health in people coming from deprived backgrounds. Although neither of these authors openly criticises traditional psychiatry, their approach to research also

parts way with epidemiology.


Rogers and Pilgrim have been interested in the issue of inequality in mental illness for sometime, as reflected in their writings (Pilgrim and Rogers, 1996, Rogers and Pilgrim, 2003). While the 1996 approach applied the usual set of epidemiological variables to mental illness, it has also looked at discrimination in the context of age, ethnicity and gender. However, it is Rogers and Pilgrim’s 2003 framework which is more radical than their 1996 approach was. It includes the services themselves as a source of inequality; and a central place is given to violence as an inequality factor. The inclusion of the services relates to the application of professional ways of working more as a means of social control than care, one which ignores lay perceptions and users’ own understanding of what mental distress and illness are about. Coercive social control comes into this discourse, but is no more than one means of such a control. The majority of professionals for clients who reflect come from a well-educated, Caucasian group. Their preference for clients who reflect their own background has been noted before in discussing inequality in terms of access to psychotherapy of ethnic minority service users by a number of authors (including Pilgrim and Rogers), a much wider range and hence a greater impact is given to this factor in the 2003 framework, which looks at the imbalance in power as the key to maintaining professional control.


Rogers and Pilgrim also take into account the existence of a more vocal and articulate user movement in most Western societies, while being aware that its impact on professional ways of thinking and working to date is negligible. This is attributed by the authors to the continuing dominance of the medical psychiatric perspective which believes in the centrality of genetic and biological approaches to mental ill health over psychosocial ones, discarding the significance of inequality which is by definition a social phenomenon.


The inclusion of various facets of violence in their framework merits attention too.   For them violence in the context of mental illness includes not only traditional aspects such as compulsory admission and intervention, harm to self and to others by people experiencing mental illness, but also their victimisation by the community, as well as the impact of warfare on people’s mental health.


The complexity of understanding violence and inequality in mental illness is highlighted by their use of the causal model created by Hiday (1995, reproduced from Rogers and Pilgrim, 2003, p. 158) which links social stratification with mental illness and violence.


Table Three

Table 3: Casual model linking social stratification with mental illness and stratification

Source: Rogers, A & Pilgrim, D (1995), ”Mental Health and Inequality”, Palgrave Macmillan


Rogers and Pilgrim also point out that although misuse of alcohol and drugs is recognised as leading to violent behaviour, it is misleadingly attributed to users’ mental illness. Such a categorisation reinforces the public’s and the politicians’ tendency to over-focus on mental illness as a source of violence, while undermining the aspect of victimisation of mental health service users by perpetrators who are not usually mentally ill (though a minority of inpatients also do victimise other patients).
 

Methodological issues


The key factors to be investigated in the context of inequality in mental health are complex in so far as they are either a construct combining several variables, or that the validity and reliability of the measurements used are known to be doubtful.  For example, psychiatric diagnosis, taken for granted repeatedly in each epidemiological study, has been the subject of many studies which highlighted its problematic record in terms of reliability and validity (e.g. Scheff, 1975).


As epidemiology defines itself as the study of populations, large samples are preferred population diversity does not fall neatly into any randomisation models. Measurement to small ones. The belief in the value of Randomised Controlled Trials (RCT) to provide representativeness of these populations continues to be assumed, even though instruments are usually questionnaires in which each item merits as short as possible an inquiry, and one focused on functional issues. While only instruments proven to be

reliable are applied, their validity and their relevance to diverse groups remains debateable; the lack of a qualitative research element is also a methodological drawback.


In table 4 Shah (2004) lists eleven methodological problems in need of paying attention to in the context of studying ethnicity and inequality in mental health.

Table Four

Table 4: Methodological issues

Source: Melzer, D et all (2004), ”Social Inequalities and the Distribution of the Common Mental Disorders”, Psychology Press Ltd


While it could be argued that researching ethnic minorities raises some special difficulties, most of the issues listed by Shah are not limited in significance only to these groups, but are relevant to any socially marginalised group. The complexity of running a large scale study and analysing the data often leads to findings being published on average at least five years after the study took place; by which time they may/may not represent accurately the reality of a given population any longer.


The methodology of researching the contribution of services and of violence to inequality is at its infancy, and requires further elaboration.


The main empirical evidence


I have opted to compare British findings (Meltzer et al, 2004) with those of continental Europe (Stakes, 2004, Eurobarometer 2003), Australia (Andrews et al, 2001) and the US (Kessler, 1995, 2005) mainly due to similarities in social structure, psychiatric diagnosis and attitudes towards mental ill health. It could be argued that a comparison with very different societies could have been equally useful in

highlighting trends in inequality particular to the UK. A case could be made also for the inclusion of longitudinal studies or repeated cross-sectional research. The main British study includes comparison to eight international studies from Australia, the US and the Netherlands (Meltzer et al, 2004, table 1.3). The high risk groups evidence produced by epidemiologists is summarised in table 5.


Table Five

Table 5: High-risk as a percentage of the population aged 16-64 and the percentage of each high-risk group who suffer from neurotic disorder

Source: Melzer, D et al (2004), ”Social Inequalities and the Distribution of the Common Mental Disorders”, Psychology Press Ltd


Broadly, the similarities in findings in relation to inequality in mental health are greater than the differences. The prevalence of serious mental illness (affecting 7 people out of 1000) and common mental disorders (affecting 1 in 6 people) provides an indication of how many people suffer from mental ill health, an experience which is at the core of their inequality but one impossible to quantify.


Table Six


The most significant findings include:


A number of studies in the past have found that members of ethnic minorities had a higher rate of mental illness, and have under-utilised psychiatric services. Further clarification indicated that this was true for some ethnic minorities, but not for others, and that the dividing line is not colour or race. Thus Irish people in the US and the UK tend to have higher rates of psychosis than any group of black people; and people of Pakistani origin in the UK have the highest rate of neurosis. The much publicised finding that Caribbean men have a higher rate of psychosis has been supplemented more recently by findings from a larger study (Nazaroo, 1997, 1998)

which suggests that these men do not have a higher rate of psychosis than white men.   US findings indicate the same conclusion (Kessler, 1995).


Pertaining to common mental disorders most ethnic minority groups share a similar rate to that of the general population. There is some indication that depression is higher in Afro-Caribbeans and Africans; anxiety is higher among Irish-born and non-British white groups, and phobias more prevalent among Asian and Oriental people than in the indigenous British white population (in Meltzer et al, 2004, p.208).


The centrality of poverty is retained when looking at ethnicity; poorer people in ethnic minorities are more likely to experience mental ill health than those who are not. Current evidence related to prevalence and ethnicity may indicate changing patterns (Rogers and Pilgrim, 2003, p.30-31).


There are a number of ways in which services assert their control, including the claim

to professional expertise, monopoly over both knowledge and methods of intervention, and hence the almost inevitable rejection of lay knowledge.




Most epidemiological research on inequality does not look at the traditional indicators of violence in mental health, namely harm to others and to oneself by service users.  The statistical evidence shows a small increase in harm to others under the experience of psychosis, and a considerable increase in self harm (Monahan, 1992, Swanson et al.,1999, 2000, Appleby et al., 1997). Taylor and Gunn’s 1999 British study has demonstrated that despite the assumption of the media and politicians of an increase in homicide by identified patients during the acceleration of psychiatric hospital closure, the numbers were slightly reduced. Trieste, where there is no psychiatric hospital since1978 and when necessary hospitalisation takes place in open community mental health centre, has reported very few cases of homicide or suicide between 1978 and 1988 (Sain et al., 1988).


Rogers and Pilgrim’s overview of violence in mental illness looks at the many instances in which service users are victims of violence rather than the very few ones in which they are its perpetrators , including warfare, hate crimes, neighbourhood stigma which leads to victimisation , child abuse, adult to adult violence (mainly domestic violence), and eugenic psychiatry (the enforced sterilisation of women

patients, practised in many European countries until the end of the 2nd World War, but until 1975 in Sweden, a country known otherwise for its enlightened social policy). They highlight the attention to individual pathology when the focus should be on socially caused violence, as well as to the fact that unlimited detention without due legal process takes place only in mental health.


Implications for social work


Although qualified by beliefs, conceptual perspectives, and related methodological limitations, the findings highlight:

·   inequality does exist in mental health, coming largely out of factors external to it;

 

·   the central role played by poverty in being a major risk factor in leading to and maintaining mental illness;


·   discrimination too has a central role in creating inequality in mental health (e.g. ageism in the context of not identifying and not treating depression of older people beyond medication; abuse in the lives of children, women and men; racism in the case of ethnic minorities, stigma and victimisation in neighbourhoods, politicians’ emphasis on harm to others and under-emphasis on victimisation of service users).


·   psychosocial vulnerability factors interplay in the context of mental illness (e.g. physical illness and recent adverse life events, likely to include physical illness as one such event, which also affects the social position and socially valued roles of the ill person);


·   mental health services and their providers contribute to inequality in a variety of ways through their monopoly on knowledge and expertise and through the exclusion of other types of knowledge.


·   it stands to reason that biological factors may play a part in leading to and in maintaining mental ill health, but the evidence for this belief is not provided by the research on inequality in mental health.

 

The evidence illustrates the serious limitations incurred by locating the study of mental health within medicine as a scientific tradition (a rather separate issue from the usefulness or otherwise of medical interventions) , and vindicates the case for a psychosocial approach to mental health and illness, one in which social structural factors need to be tackled not less than psychological ones.


To anyone coming from the social sciences the centrality of poverty as a context which creates and reinforces vulnerabilities while sapping resilience is no more than a confirmation of past understanding and knowledge (e.g. Jones, 2006, Raphael, 2006). Yet the acquiescence to medicine by all mental health professions, including social workers, continues. Some of it is rooted in the status given to medicine in our societies; some of it stems from the ease of dishing out medication as compared to the complexity of providing psychosocial interventions and of securing their effectiveness. Still some more of it relates to the reluctance of professionals, governments and the general public to invest a lot more, and in more sophisticated ways, in tackling social structural factors and in fostering resilience instead of treating users as an underclass (Murray, 1994, Jones, 2006).


In the specific case of social work the separation of theory, research and policy from everyday social work, the minority position of social work in multidisciplinary teams, the relative lack of respect towards it by successive government, and the lack of

sufficient knowledge and skills for psychosocial work at different societal levels, prevent it from taking the central position it should take.  These obstacles apply not only to British mental health social work.


More than their colleagues in other Western countries, British mental health social workers (MHSW) are heavily focused on legal work related to compulsory admissions, in their role as Approved Social Workers (ASW) (Barnes et al., 1990).  In Australia MHSWs are responsible for care management, and for compulsory treatment orders in the community (Brophy and Ring, 2004). Some US MHSWs are responsible for planned discharge from inpatient facilities, while the majority is engaged in private practice psychotherapy. More voluntary sector social work is provided in Canada (Shera et al., 2002). Continental European MHSWs offer a range of services, from sorting out financial benefits to leading community work projects, but focus less on individual psychological interventions.


The proposed British mental health legislation will make it possible for other mental health professions to carry out the legal duties presently performed only by social workers, namely providing an additional perspective to that of psychiatrists (and GPs) during the process of compulsory admission. Rightly, social workers are afraid that this change will dilute further the psychosocial dimension in the assessment, given the lack of training and professional socialisation into this dimension by members of the other professions (Rapaport, 2006). Wrongly in my view is the lack of discussion as to what else could/should social workers add to their ASW work, or replace it with, when this task will be shared with mainly nursing colleagues.


Elsewhere I have highlighted the price paid by social workers and their clients for the over-emphasis on ASW work (Ramon, 2006), which meant severely cutting down on casework, family work, group work and community work in the field of mental health. By now community work has been taken out of social work altogether for political reasons, and to the limited extent that it is taking place in mental health it is carried out by voluntary sector organisations (Seebohm et al., 2005). The central role played by some social workers in initiating user involvement in mental health has not only not been recognised within and outside social work, including by service users, but has not led to diffusion of such an involvement in everyday practice, where it could have a truly culturally transforming role.

The change in the British Mental Health Act provides an opportunity for MHSW to re-consider its values, knowledge and skills base, both within the context of each society and internationally, along the lines developed within the critical perspective of social work (Allan, Pease and Briksman, 2003) . This would require moving away from the defensive position MHSW tended to occupy within the mental health system and vis a vis governments.


Instead, MHSW needs to move to:


·   genuine partnership in working with service users, their family members and friends (Beresford, 2005),

  

·   become more engaged in the work to be done about the reduction and eradication of poverty as it relates to mental health , which includes being actively involved in social inclusion work (Repper and Perkins, 2003).

 

·   be active in the development and implementation of recovery work (Roberts and Wolfson, 2004, Wallcraft, 2005, Ramon et al., 2006, Ramon et al., 2007).


·   engage in the application of the strengths approach and the development of resilience layers at the individual and group levels (Norman, 2000, Greene, 2002).


·   move away from its anti-intellectual, anti-research stance (Jones, 1996) to initiate its own research and theoretical framework in mental health.


These are not easy options to put into practice, as they would require a significant shift in training, knowledge and skills in addition to government’s investment and work on public attitudes. However, their implementation would mean that social work would be able to claim that it attempts to move away from its current contribution to the status-quo re inequality in mental health.


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Notes:


Paper prepared initially for the first ESRC sponsored seminar of the Social Work and Health Inequalities Research network: 20th January 2006


Biographical Note:

Shula Ramon is professor of interprofessional health and social studies at Anglia Ruskin University and a visiting professor at the Centre for Recovery at Hertfordshire University.  A social worker and clinical psychologist by her training, she has been researching community mental health internationally, involving users as co-researchers, and more recently focusing on social inclusion and recovery
from mental illness.  She has published extensively on these issues.
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