Feature

Light at the end of the tunnel?

Fifteen years after a congress dedicated to the rights of people with mental illnesses, Mo Hutchison looks at how much progress has been made towards meeting its demands

There was optimism in the air. Mental health service users and professionals from a number of countries had gathered in Brighton for a congress dedicated to agreeing a charter encompassing the ‘rights of the mentally ill’. Not only was it an exciting and challenging agenda but the deadline for implementation was set for 2000, so we had 15 years – plenty of time – to achieve our objectives.

That deadline has arrived and so now is the time to revisit the Brighton declarations and assess how much progress has been made towards meeting them.

The upper box opposite details part of the aims and objectives of a section of the 1985 charter. It is ironic that, rather than abolishing compulsory treatment, the proposed Mental Health Act looks set to extend such ‘treatment’ to the community.

There has been much talk of compulsory treatment in the community not meaning forcibly injecting people over their kitchen tables – but where exactly is it to take place? If a person is refusing medication, they are unlike to wait about to be taken to a clinically appropriate place to receive this unwanted treatment. The other points listed are no nearer to realisation and it is unlikely they will ever be realised.

The closure of large psychiatric institutions is continuing apace but there have been gloomy verdicts on the efficacy of community care. ‘Community care has failed,’ declared the former health secretary Frank Dobson.

The real failure is the refusal by successive governments to admit that successful community care needs adequate funding. The present government and media priority seems to be to concentrate on the tragic but small number of homicides committed by people with mental health difficulties which, contrary to popular myth, has not risen for many years.

The current emphasis has been on dragging people into services whether or not they want to be there. The government is proposing that people who are considered to have ‘severe personality disorders’ will be detained for unspecified lengths of time even though they have committed no offence. All of this does not accord with the statements set down in the lower box opposite.

A lack of appropriate and supportive housing is still a problem and many people remain in hospital not simply because there is nowhere else suitable for them to live.

Very few areas have a ‘range of locally based services’. Typically it is a case of ‘there is this service or there is nothing’. This does not acknowledge the diversity of experience and needs, nor the necessity of providing services which are culture and gender appropriate.

Where there is a range of services it is usually because active voluntary organisations are filling the statutory gaps. There is no inherent problem with this, but the concern is that they frequently do so with inadequate and insecure resources.

Another area which the charter examined was the link between poverty, unemployment and mental health problems. It has long been recognised that poverty is both a cause and effect of mental health difficulties and people who experience such difficulties are deeply uneasy about the proposed welfare reforms.

The current level of benefits does not allow most mental health service users to enjoy an ‘ordinary’ life with the potential for helping them to overcome their problems. They are very worried that any cuts in benefits or changes in criteria will make this situation even more serious.

In terms of employment, there has been some progress with the introduction of the New Deal for the Disabled and the Disability Discrimination Act 1996, but there is still much to be done. Estimates vary but around 90 per cent of people with serious mental health problems are thought to be unemployed. There are many reasons for this, including employers’ attitudes, the lack of suitable employment and mental health professionals, who have a tendency to make far-reaching, negative assumptions about users’ capabilities.

The real battle has been to gain recognition that mental health falls within the remit of both the DDA and New Deal for the Disabled. Disability is usually considered solely in terms of physical disability. But anyone with mental health problems will know that their problems can be equally disabling, particularly when it comes to discrimination, as Sara Dunn reports elsewhere in this issue.

The DDA compels employers to make reasonable adjustments to accommodate disabled employees and there are many examples of what these adjustments might be in mental health terms. The impact of these government measures has yet to be judged.

The government’s mental health agenda could not be considered progressive, in fact, many argue that it is oppressive. This is against the letter and spirit of the 1985 charter which, under the heading ‘Self- Determination as a Human Right’ declared: ‘The labelling, stigmatising, incarceration and ‘treatment’ of those who deviate from predominant social norms serve the interests of a powerful minority who gain profit and status.’ While it is difficult to challenge this ‘powerful minority’ – the pharmaceutical industry and mental health professionals, particularly psychiatrists – there has been an upsurge in the user movement. Since the congress, three major user organisations have been formed: Survivors Speak Out; the United Kingdom Advocacy Network, and Mindlink.

The user movement embraces two schools of thought: abolitionists who call for an end to psychiatry as we know it; and reformers who wish to change the present system. But there are a number of goals which unite the movement:

• the empowerment of service users;
• the involvement of service users in all aspects of mental health services;
• the right to campaign against unacceptable practices within mental health services;
• the provision of advocacy for everyone who wishes it.

The charter also devoted sections to the discrimination experienced both by women and users from black and minority ethnic communities within the mental health system. It stated that: ‘All governments, public authorities and mental health organisations must recognise the dangers of misdiagnosis and mistreatment of illnesses based on differences in cultural backgrounds.’

Sadly very little progress has been made in this area. Young, black men continue to be over-represented within secure mental health facilities and black men and women continue to receive physical treatments such as drugs and ECT rather than talking treatments. Where innovative services do exist they are usually within the voluntary sector rather than within mainstream services.

The charter rightly argued that there is ‘a lack of professional awareness of the effect of racism on mental health’, and that all staff should be trained in order to increase such awareness.

There has to be a real sea change in professionals’ perceptions of users from different cultural backgrounds but, at present, it is difficult to imagine how this might be achieved.

Rather more progress has been made with regards to women with mental health problems. The charter stated: ‘Women should be able to choose mental health services run by women for women.’ Many service providers do now allow users to choose a key worker of their own gender if they wish to and it is practicable. Mixed-sex wards are being phased out and all new builds must have single-sex wards. Where there are mixed-sex wards, providers are sometimes able to designate women-only spaces.

Recently there have been hopeful signs that the government is giving more positive thought to mental health, in the form of the long-awaited National Service Framework and the establishment of the social exclusion unit. It is too early to evaluate what effect these measures will have but they do indicate a recognition of the impoverished lives people with such problems have to endure. They also act as a counterbalance to the more reactionary parts of the government’s proposals.

The Brighton Congress in 1985 was an exhilarating and hopeful event. Some steps have been taken towards achieving its aspirations but the basic philosophy of removing the stigma, discrimination and marginalisation of people with mental health problems is no nearer realisation. I wonder how much longer we will have to wait.