The final report by the Centre for Mental Health, The Commission for Mental Health Equality, is a key reading for any education professional interested in improving mental health in their setting.
It firmly positions mental health as something beyond the individual but is something that is a collective good and a collective responsibility.
The report highlights stains on our society, such as the fact that poor children are four times as likely to have a mental health problem before they leave primary school than their wealthy peers, or the injustice that students with a learning disability are three times more likely than average to have a mental health problem.
These and other mental health inequalities are entrenched and have been sidelined for too long. But change is possible.
Below we summarise some of the main points:
Cause of mental health inequality
Anyone can have a mental health problem and most people do at sometime in their life. However, the chances of having a mental health problem are far from equal. The interlocking nature of inequalities across multiple dimensions determine overall risk.
Wealth
Poverty, absolute and relative, is toxic for mental health. 76% of mental health inequality is a consequence of economic inequalities. Child poverty in particular is not just a short-term risk to mental health: it has an effect throughout life. More unequal societies create stronger narratives about ‘superiority and inferiority’ which increase stress levels in individuals. People who lack money and status may feel social anxiety and shame, which feed into instincts for withdrawal and subordination, increasing vulnerability to mental ill health.
Power
Power inequalities have a profound impact on mental health. Being heard, being able to make decisions in life and being treated justly are all essential ingredients for good mental health. In schools these inequalities are seen in homophobic bullying or in the higher use of restrictive interventions and exclusions on Black or disabled children. The education system also has a “hidden curriculum” as seen by streaming, school trips, sports and assemblies as well as the broader social ‘segregation’ between schools across neighbourhoods.
Inequalities in power and privilege frequently intersect with ‘protected characteristics’ such as race, religion, disability, sexuality, gender and gender identity; and also with social class.
For an individual, being subject to discrimination is a traumatic experience. There is also a community level effect. Exposure to others’ experiences and the fear of abuse can have a collective impact on mental health. Seeing people who are Black or Muslim or trans or disabled repeatedly being treated unjustly, either in person or on television or social media, can have a profound cumulative impact.
What perpetuates mental health inequalities:
These issues have been known for a long time, yet they persist, why?
The individualised approach:
An exclusive focus on the individual will miss the point for many. Whilst self-care and seeking support is important, it is one just piece of the jigsaw. Yet, the focus is on the behaviour and lifestyle of the individual, rather than recognising the collective and structural determinants.
Discriminatory narratives:
Do we address the suffering of all people equally?
The predominance of the ‘medical model’ has been extensively challenged in recent years, led by campaign groups from the mental health service user and survivor movement. Their voices have helped to shift the focus of mental health services towards a more ‘social’ model which appreciates that people often need their social and economic environment to change, rather than just be supported to ‘fit in’ to the environment as it is. But this has not been the case for everyone. And for African and Caribbean communities in particular, from childhood onwards responses to distress are more likely to be punitive – including the use of restrictive interventions in school, the involvement of the police and the use of physical restraint in mental health services.
National policies & strategies:
The drive to speed up referrals and access to treatment and crisis care has left little scope for innovation or to reshape support to ensure equality. The best mental health support is focused on people’s assets and hopes, including in relation to removing barriers of inequality, and offering properly supported peer support opportunities – but these approaches are not yet the norm.
Often, equality has been an afterthought with little clear direction or resource given to it.
Austerity:
Austerity affects mental health in multiple ways: for example by reducing the value of social security benefits and reducing the provision of services that promote mental health in communities, such as early years, youth work and social care services for adults and children. That some of the biggest cumulative effects are felt by children and young people, resulting from disinvestment in early years services, arts-based activities in schools, libraries, youth services and benefits payments for families. Perversely, austerity policies tend to direct public spending to high-cost crisis services by reducing spending on services that prevent problems or intervene earlier.
What can be done?
Below we look at some of the principles to ensure mental health equality.
Inclusive education:
“One of the biggest obstacles to inclusive education – where all children belong and can flourish – is the lack of belief that it is possible.”
Children’s experiences of school, and young people’s experiences of college and university, have a major impact on their mental health. Education settings at every stage can have a positive and powerful impact on our mental health. Inclusive education in relation to sexuality, for example, has been shown to reduce homophobic bullying in schools, preventing a significant risk factor for poor mental health. Adopting a ‘whole school approach’ to mental health benefits everyone but can have particular benefits to those facing the greatest risks.
For children facing some of the greatest barriers to a good education, such as those with learning disabilities and autism, and those with severe behavioural difficulties, the use of restrictive interventions and exclusions (including off-rolling) cause significant and lasting harm to both mental health and wider life chances.
Mutual support:
Foster mutual, or peer support, networks. Encourage them to flourish and enable them to make changes within the school.
Foster collective impact:
Work with outside agencies, and other schools, to deepen impact across the wider system, bringing back learning to your own setting. Belong to professional networks seeking mental health and wider equalities.
Ensure positive identity:
Celebrating a community’s culture and building a positive identity can help both to challenge oppressive ideologies and reframe mental health as something that can be created collectively.
Allyship:
Education settings seek to ensure equality by focusing on supporting all their pupils to thrive. The most effective schools and colleges make equality core to their purpose, plans and operating model rather than relying on one-off activities. Ensuring good working conditions, fair and equal pay, just policies and practices, and freedom from bullying are all critical elements of a healthy workplace.
Tailoring support:
What this looks like will inevitably be different in different localities and for different communities. For some, interventions need to be re-designed or adjusted: for example for autistic people or those with learning disabilities. For others, including deaf people or those whose first language is not English, specialist interpretation services may be needed. Peer-led services, resourced and supported, can also be helpful for communities in terms of gaining vital hope and empowerment, as well as to fill a gap for those who do not trust formal services.
People with lived experience, in whatever form, bring new and vital knowledge to the table. Dismissing, denigrating and denying this is a foundation for social injustice. Advocacy from lived experience challenges this injustice and shifts the balance of power towards a more equitable exchange. This requires a commitment to cede power and to be prepared to learn from lived experience.
Engagement:
Engagement can be particularly important for young people, and especially those who are most marginalised. Further education (FE) colleges are an important and often overlooked setting for mental health support, yet they disproportionately serve young people who have had the least opportunities and who find formal health services least attractive: for example those who have been excluded or ‘off-rolled’ during secondary school, and those taking on apprenticeships, where formal mental health support is less available.
Holistic:
Mental health support needs to address and respond to the struggles many people face while living with mental health difficulties. Help with family, study and relationships is an important aspect of mental health support that has often been regarded as an add-on to clinical care.
Addressing the structural inequalities that underlie poor mental health moves services away from an individualised approach that prioritises treating illness or promoting ‘resilience’ towards a collective approach that sees people in their social context and seeks to make change happen around them too.
For example, the charity Youth Access provides “advice and information services that can help young people access their rights and entitlements, and address broader issues that go hand in hand with mental health – such as housing, money and relationships – sometimes referred to as the ‘social determinants’ of mental health.”
Responsive:
For many people, mental health difficulty is connected to experiences of oppression, disempowerment and violence. Poor mental health can result from experiences of racism, bullying, exclusion and injustice, and mental health support need to be able to offer the opposite to these experiences. Approaches such as trauma informed care and cultural competency can facilitate this by creating a sense of safety and by seeking to listen to and understand people’s narratives on their own terms.