July 20, 2003

Mark Bertram, occupational therapist and vocational service manager with the South London and Maudsley NHS Trust (Lambeth), works in an area of high deprivation.

Despite the obstacles, he argues mental health service providers should attend more to how such disadvantage effects people's lives.

Contact: markbertram@mail.com

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A prelude: Reflections on Self-Praxis
I work in mental health services in an area having the highest level of violent street crime nationally, very high levels of socio-economic deprivation, unemployment, drug abuse and 'psychiatric morbidity'. It has been described, in the press and through graffiti, as a war zone, ghetto and dumping ground.

To use the same analogies, the people I meet appear to be living examples of social inequality and the seriously wounded casualties. In my experience, over 14 years, the people I work with tell stories about their experience of distress that are entirely understandable in the lived oppressive context of what has happened to them. The key point is many 'have been done to or neglected' and have suffered the impact of gross inequalities to the extent that they cannot cope anymore. Many consistently describe struggling with extreme emotional and social deprivation, abuse, traumas and a lack of educational or vocational opportunity.

I have learnt through my own experience of mental distress and living in a therapeutic community that "the important thing is to realise why people, feel that they are going mad, feel they cant cope…usually with the suffering you're talking about- social and/or personal invalidation" (Berke, 1974, p233).

My own oppression that led to a period of self- destructive madness emerged through the conditioned fixing of male gender identity and imposed responsibilities. "As a boy I was not allowed to feel scared…if I cried or broke down I was a sissy not a man. My father was lost at sea when I was nine years old. I was informed…that I was now the man of the house, had to be strong, keep my chin up and look after the women…the forced denial of the experience of grief was impossible for me to cope with" (Bertram, 2003). What brought me through it was engaging with people who were able to create safe conditions for me to tell my story so I could feel heard. Genuine interest, tenderness and felt acceptance enabled me to work through deeply rooted feelings of despair, loss and pain to begin to get some sense of confidence and eventually commit myself to a role.

As a worker and service manager in vocational services the effects of poverty are generally over looked in mental health services. Helping people into employment does not receive the priority or resources needed. Having been unemployed for a long time I have described my experience "I felt deeply insecure, scared and devalued" (Bertram, 2002). In the same article a user describes theirs " I got angry then it hurt, I just ended up in a gutter alone, no one respects or cares about you, its easier to just give up, I did" (p8). Many people from black and ethnic minority groups state consistently to me that they are discriminated against by employers and the only jobs they could get were low paid and menial. A Black user once said to me that he was told he was a 'McDonalds dodger'.

Describing the affects of poverty Beresford (2001) states "In terms of loss of choice and hope, sense of fear and worthlessness and sheer wretchedness I would not wish it on anyone…" (p2). My experience of working with people reflects exactly what Williams (1999) states, "There can be no doubt that social inequalities are a major determinant of the mental health of people who belong to oppressed social groups".

Most of the work my colleagues engage in is focused on trying to help people clobbered and disabled by the miserable effects of poverty and deprivation within a shaming benefits system and discriminating society.

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Introduction
Here I am concerned with the nature, scope and impact of social inequalities that impinge on the positioning of marginalized groups in western society. The argument is structured into three parts: the context briefly describes how the difficulties that bring people into contact with mental health services are differentially perceived between medical and social variables of analysis. I review and analyse some key evidence associated with two important lynchpins of social inequality in the form of gender and racism. The discourse and impact of social inequalities is then assessed in relation to the implications for service development and the dynamics resisting change.

Context
Currently, the difficulties that may bring social groupings into contact with mental health services are multifaceted. Firstly, western psychiatry locates and interprets human experiences, reactions and problems of being in the world within individual minds and bodies, social or extraneous factors are accepted, not as causes of mental illness but "merely precipitants" (Fernando, 1995, p15). Secondly, the contrasting argument is that the impact of disadvantage through social inequalities is "causally linked to the despair, distress and confusion that is named mental illness" (Williams and Lindley, 1996, p3).

The ambivalence for understanding the medical implications of social inequalities on mental health then is: 'whether' peoples thinking and actions- that psychiatry may define as symptoms of a disorder- can be understood as "creative responses" to a range of psychosocially intolerable oppression(s) and therefore transcending medical science via the social construction of inequalities tied to social variables of analysis (Williams, 1999, p31).

Indeed, according to Williams and Watson (1988) the extensive evidence indicates that social variables are inextricably linked: "social inequality exists when an ascribed characteristic such as sex, race, ethnicity, class and disability determines access to socially valued resources" (p292). Consequently, it has been argued that the relationship between social inequalities and its affect on mental health can be best understood through examining the evidence of serious disadvantage linked to inequitable access to resources, processes of subordination and serious abuses of power (Williams, 1999, Williams and Scott, 2002).

Gender and Mental Health
Gender, as a social construct, fixing of identity and life determining characteristic influences significantly the symbolic, material and unequal position that women are subjugated to globally (Bertram, 2003). For example, the World Health Organisation (W.H.O) report extensive research where findings correlate rates of 'psychiatric morbidity' with 'epidemiological' clusters directly linked to poverty, social disadvantage and deprivation (Kleinman, 1998, W.H.O., 2002).

However, some writers claim that despite three decades of research on gender identity and a wide range of risk factors, none can fully explain or single handedly account for gender differences in diagnosed 'mental illness' (Nolen-Hokesma, 2001, Segal, 2001). In contrast, Prior (1999) states it is now accepted that explanations must be located within the social milieu, she cites Weisman (1991) "epidemiological difference is not reducible to biological factors or methodological artefact but can be traced instead to extrinsic features of the social milieu and inequities with respect to cultural domains of power and interest" (p279).

Access to resources such as money, power and status are key indices of inequality (Williams, 1999). Globally, women account for 70% of those living in absolute poverty and generally people diagnosed with 'mental illness' are economically poor and face more severe life events (Ramon, 1996, United Nations Development Programme, 1997). Gendered inequity in the division of paid labour is reflected through U.K. statistical evidence. On average women's gross income is 49% of men's with 43% of women working part time (Office for National statistics, 2002, Women and Equality Unit, 2001).

Women also face chronic burdens associated with their assigned status that places them at greater risk (W.H.O, 2001). The multiple role demands usually feature an around the clock taken for granted care function involving the responsibilities of being mothers, wives, carers, cooks and cleaners for others (Paltiel, 1993).
It is the unending and devalued nature of these mainly unpaid tasks that can lead to poor 'mental health' (Miles, 1988).

There is extensive evidence that women are subjected to oppressive subordination processes involving serious abuses of power mainly by men (W.H.O, 2001). For example, the high level of physical and sexual violence (W.H.O, 2002). The most endemic form of violence against women in developed or developing countries is domestic violence, global prevalence ranges from 16%-59% (W.H.O., 1997). Sexual assault against females in childhood or adulthood have also been identified as the most likely trauma event resulting in post traumatic stress disorder and admission to secure services in the U.K. (Darves-Bornoz, 1997, Williams and Scott, 2002).

Many feminist writers have also consistently argued that gender is strongly embedded in the social construction, categorisation and control of `mental illness` (Busfield, 1996, Prior, 1999). According to Showalter (1987) "While the name of the symbolic female disorder may change from one historical period to the next, the gender asymmetry of the representational tradition remains constant" (p4). It is claimed that psychiatry is a form of gender discrimination and subordination process because of the way women's experiences of social inequality have been medicalised (Russell, 1995). Women are more likely than men to receive electro-convulsive therapy even where the evidence suggests that the main conditions they are 'diagnosed with' have strong social origins (Busfield, 1996).

Therefore, being female may be a risk to women's mental health because apart from "trauma, exploitation and discrimination" the affects of inequalities are hidden and mediated by labelling women mad (Williams, 1999, p36, Burstow, 1992).

Consequently, the evidence has prompted strong arguments that it is "both more accurate and useful to conceptualise women's mental health problems as responses to-and sometimes as creative ways of coping with- damaging experiences that are rooted in their lived experiences of inequality and abuse of power" (Williams and Scott, 2002, p6).

The Problematic of Racism
"Difference on the basis of skin colour routinely attracts discriminatory behaviour, racism is rife" (Trivedi, 2002, p72). The health of Black and ethnic minority groups forms part of a wide social exclusion agenda that covers inequality indices such as unemployment, education, poverty and poor housing (Bahl, 1999). The impact of inequalities stemming from sources of racism can be identified through exploring the psychological, material and social consequences (Patel and Fatimilehin, 1999).

According to McKenzie and Murray (1999) "One can only speculate on which social factors are involved" (p57). However, in contrast, the devastating psychological consequences of racism through the processes of oppression and forced assimilation have been described in depth, "Feelings of confusion, vulnerability, powerlessness and hopelessness with subsequent emotional and psychological distress often accompanied by self destructive feelings…may lead us (voluntarily or involuntarily) to mental health professionals (Trivedi, 2002, p76).

Material consequences of racial disadvantage through unemployment, deprivation and the consequent financial strain also have dangerous implications for the functioning and stability of families in whole ethnic communities (Patel and Fatimilehin, 1999). Social inequalities have been found to determine the security of attachment for children generally with social advantage being associated with secure attachment (Early Child Care Research Network, 1997).

The structured nature of socio-economic inequalities and the implications for subject positioning are further described by Davey (1999) "The absence of adequate income and occupation are strategic aspects of a general lifestyle of systematised emotional, relationship and experiential deprivation. The mental health problems are a result of this" (p267).

For example, despite the Race Relations Act (1976), racial discrimination in employment practices has a long history and recent studies highlight this continuing: 15% of white men where unemployed compared to 31% of Caribbean's and 42% of Bangladeshis (Modood, 1997). Women from all ethnic minority groups are the least likely to be in employment (Commission for Racial Equality, 1997). Generally, the research data have also demonstrated that unemployment results in increased rates of depression, anxiety and admission rates with evidence of a link to increased risk of suicide (Moser et al, 1987, Warner, 1994, Lewis and Sloggett, 1998).

The social impact of material deprivation is also linked to a reduction in social, economic and political power that can result in the marginalisation of whole communities (Patel and Fatimilehin, 1999). These authors cite Fernando (1984) to make a further point that racism toward black and ethnic minority communities is implicated in material, social and emotional suffering and the subjective experience of powerlessness, limited control over social realities and lack of opportunity may combine to lead to 'depression'.

There is also compelling research evidence that Black and African-Caribbean people encounter a range of difficulties in the way they access mental health services. For example, they are more likely to be sectioned with police involvement, forcibly medicated with high doses and 3-6 times more likely than white people to receive a diagnosis of schizophrenia (Bahl, 1999, Sainsbury's centre for Mental Health, 2002).
Despite a national growth in the user movement and policy exhortations for users to be involved at all levels of provision, Black users voices are "not heard within the mental health system" (Patel and Fatimilehin, 1999, p67, Sassoon and Lindow, 1995).

Implications for service development
The evidence presented here highlights some of the sources and impact of inequalities on people's lives that may bring them into contact with services. However, there is evidence that most mental health services do not meet the needs of women or Black/Ethnic minorities because they replicate the discrimination, fear, oppression and abuse reflected in society (Williams and Scott, 2002, Sainsburys Centre for Mental Health, 2002).

This can happen through Institutional racism and subordination processes leading to what Trivedi (2002) called the 'spiral of oppression'. This author argues, through personal experience, "Societies response to…distress is treat it within mental health services in a system of medical and social care that rather than understanding and challenging oppressions that give rise to mental distress, reinforce them with their own oppressive attitudes and practices" (p77). Therefore, unless social inequalities, as a cause of mental distress, are taken seriously and made explicit, mental health services will be damaging to users and a waste of public money (Williams, 1999).

Services would require radical changes to even begin to meet the needs of Black and Ethnic minority groups and dispel the stigma and fear associated with mental health provision. For example, dealing with issues of empowerment, user involvement in determining need and quality, developing community based preventative services and alternative non-eurocentric models (Patel and Fatimilehin, 1999).

The implication and challenge for services then is to recognise the material, psychological and social consequences of social inequalities on women's and men's lives and cultivate a commitment to changing the nature of provision. For example, by mainstreaming gender "as part of the automatic consideration of inequality issues in policy and practice development" (Williams and Scott, 2002, p10). These authors highlight development in the areas of policy, practice, training and user participation. They also propose specific service components based on evidence and service user views. In summary, these include: psychological and physical safety, users influencing provision and development, service cultures that recognise the consequences of inequalities, staff who are well informed about the social origins of distress and empowered staff mindful of relational power abuse and who are well trained and supervised (p12).

A fundamental implication for mental health workers during assessment and intervention is that they need to really listen, understand and respond to what users are saying about their condition as often alienation, deprivation, lack of hope and income can create responses that psychiatrists call symptoms (Austin, 1999). Nationally rates of unemployment for people diagnosed with serious 'mental illness' have been reported as ranging from 66% to 100% (O`Flynn, 2001). This shocking level of social exclusion also requires huge investment with vocational developments best guided by the experiential insights of service users (Bertram, 2002).

Dynamics resisting change
The development of disciplinary structures and techniques as a modality for the exercise of power and subordination processes that put people where society feels they belong is well documented (Foucault, 1977, Powell, 2002). Mainstream mental health services are reluctant to identify social inequalities as a determinant of mental health because "promoting equality inevitably involves entering into conflict with the dominant social arrangements that help to maintain existing power relations" (Williams, 1999, p42).

The status, income and power that some health care professional roles bring in comparison to service users income and status are also highly defended (Linnett, 2002). Psychodynamic defences by staff have been identified and include "serious and worrying splits which often lead to unhelpful or damaging projections e.g. demonising others" (Heginbotham, 1999, p254).

Constraints to change also include the increasing power of the illness model and resistance from professionals to embrace new ways of working based on insights gained from personal experiences of mental distress (Pilgrim and Waldron. 1998, Barnes and Bowl, 2001).

Williams and Lindley (1996) have also highlighted that changing mental health services poses very real difficulties that "are rooted in the structural inequalities in our society and in the gross inequalities between those who provide and those who use services" (p11). They argue that it is unrealistic to expect people with least power (service users) to change services and we must establish "better ways of struggling for change together" while acknowledging the effects of race, gender, class, age and sexuality on mental health (p11).

Conclusion
Brundtland (2000) the Director General of the W.H.O. has stated "mental health depends on some measure of social justice" (p4). However, the evidence presented here indicates there is little of that around. Structured social inequalities linked to inadequate access to resources, subordination process and serious abuses of power are implicated directly with the difficulties that bring people into mental health services.

Trivedi, (2002) also confirms the central problem with how these difficulties are perceived and treated, "Perhaps now is the time really to acknowledge the social causes of much mental illness and tackle them, rather than leaving the largely biological discipline of psychiatry to deal with the casualties of social inequalities" (p82). At the heart of inequality within mental health services is the fact that professionals still define and evaluate quality and make decisions about the treatment that affects people's lives deeply. According to Keating (2002) the challenge facing services "lies in recognizing the relevance of ethnic [and gender] identity in relation to other determinants of need and thus determining appropriate services".

There are increasing calls for distress to be understood at the lived site of struggle rather than located as individualised symptoms outside of the wider socio-political context (Bracken, 2002).

However, the ongoing stratification and division of society that leads to modernised poverty and inequality prompted Illich (1978) to describe the impact that has not changed, " This new impotence is so deeply experienced…it deprives those affected by it of their freedom and power to act autonomously…mutilated by their reliance" (p8).

The power holders of our world keep pushing the consumerist vision with the promise of reaching, someday, a global market and democratic utopia but this ideology also can result in a "killing machine" (O'Sullivan, 1999). The peacetime damage comes from the structured nature of social inequalities it leaves in its wake with mental health services bursting at the seams trying to cope with the casualties. If this is not taken very seriously, made explicit and addressed at the micro and macro levels of society and service provision, the evidence suggests "Innovation without change will continue" and the suffering will get worse (Brandon, 1991, p172).

Acknowledgements:
Thanks to Peter Linnett, Jennie Williams, Frank Keating and Jason Powell for various forms of inspiration.

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