Social discrimination and social justice

All human beings are born free both in dignity and in rights, so why is it that individuals who go on to develop and experience mental illness are seen as a soft target for discrimination at a number of levels and in various domains in their daily lives? This discrimination is damaging, derogatory, and demeaning, thereby making individuals with mental illness second class citizens. By association, such discrimination also has an impact on people who look after individuals with mental illness (whether they are professional or lay carers).

World Psychiatric Association (WPA) in its 2014–2017 Action Plan, decided to look at public mental health agenda along with discrimination against people with mental illness. WPA represents over 250 000 psychiatrists from 117 countries around the globe, and is therefore interested and committed to challenging discrimination. It commissioned the Centre for Mental Health Law to conduct a survey of as many countries as possible, studying their laws for discrimination in areas of employment, voting rights, funding, and other potential aspects of individual functioning.

As has been shown in the case of racism (UNESCO, 1967), all human beings belong to the same species and descend from the same stock. Thus, no illness—be it mental or physical, acute or chronic—should lead to discrimination of any kind whatsoever. Social discrimination against people with mental illness is a global issue and it covers a range of spheres which influence daily living and daily functioning. Social discrimination appears to be lodged in the system and, therefore, can be pervasive and intrusive, and stop people from reaching their full potential and, more importantly, labelling them changes their identities. Micro-identities related to race, gender, age, religion, sexual orientation, and other components all get trumped by the label of being mentally ill.

Social discrimination is defined as sustained inequality between individuals on the basis of illness, disability, religion, sexual orientation, or any other measures of diversity.

Social justice is aimed at promoting a society which is just and equitable, valuing diversity, providing equal opportunities to all its members, irrespective of their disability, ethnicities, gender, age, sexual orientation or religion, and ensuring fair allocation of resources and support for their human rights. Any number of diverse factors, including those mentioned above, but also education, social class, political affiliation, beliefs, or other characteristics can lead to discriminatory behaviours, especially by those who may have a degree of power in their hands.

Stigma is a prejudiced attitude and is readily applied to people with mental illness (especially to those with severe and serious mental illness such as schizophrenia and bipolar disorders), and widespread insidious and pervasive stigma leads to discriminatory attitudes and practices. Stigma can also explain widespread negative attitudes and behaviours, as well as negative cognitions and structures which create and perpetuate inequities.

In their book The Spirit Level, Wilkinson and Pickett (2010) question why it is that ‘at the pinnacle of human material success and technical achievement, we find ourselves anxiety-ridden, prone to depression, worried about how other see us, unsure of our friendships, driven to consume with little or no community life’ (p. 3). The social contract, social capital, and social contact all appear to be missing. With these changes, perhaps social discrimination is increasing, as is intolerance against not only people with mental illness but also against sexual variation, other types of disability, religion, and other factors, which identify people as not ‘us’ but ‘them’. Perhaps embedded within discrimination is the notion of shame, which has been identified as the social emotion (Scheff, 1988), meaning that shame is to do with feeling foolish, stupid, ridiculous, inadequate, defective, etc. However, shame about our own actions or perceived or real threats to our way of life may well contribute to the isolation of the other, who may be different from us on any different number of parameters. Community life and mutual trust may lead to co-operation but, with increasing globalization and increasing inequality, a large part of the population feels alienated. The inequality in society leads to inequality towards various groups, most evident in discrimination against women. Income inequality and women’s status are interlinked. In cultures defined as feminine by Hofstede (2000), the equal income status between men and women not only changes the standing of women towards a more equal footing, the attitudes to child rearing also change, thereby influencing the growth and the development of the next generation.

Wilkinson and Pickett (2010) observe that more people suffer from mental illness in more unequal societies, more so in women. Whether this is associated with social attitudes to women and their place in society or some other explanation is difficult to ascertain. Societies with poor levels of trust and weaker community life have worse levels of mental health. This, combined with discrimination, leads to more exclusion of people with mental illness. Studies among animals show that low social status affects levels of and responses to different chemicals in the brain (Wilkinson & Pickett, 2010). Thus, social expectations and social aspirations if not met may well contribute to a sense of poor self-esteem and poor self-image, leading to increased likelihood of poor mental health.

Racism and racial discrimination have shown quite clear patterns of rates of mental illness, especially in minority black groups. These have been attributed to poor opportunities and other social factors, including disparities in aspiration and achievement (Bhugra, Mallett, & Leff, 1999). Such institutionalized discrimination leads to further alienation, increased inequality, and higher rates of mental illness. Other discriminations, such as homophobia, have also been shown to have increased levels of mental illness.

Race and racial discrimination are often ignored in service planning and service delivery. Racial discrimination is based on the concept of race that one race deserves privileges related to health, money, and education over another. Hacker (1992) notes that racism is not always based on ignorance, in the same way discrimination is not. Changed attitudes following education may not always translate into changed behaviour. Hacker (1992) goes on to argue that racism (leading to racial discrimination) has often been so used and over-used that it has lost serious meaning. He illustrates inequality between the whites and blacks on a number of parameters, such as education and employment. Interestingly, he also points to the voting intentions, voting patterns, and the differing attitudes towards black voters by the two major political parties in the US. Even though his observations are nearly a quarter of a century old, a lot of points he makes are valid even today. Discrimination against various ethnic groups by the white majority brings out similar attitudes and behaviours which can create a multi-tiered society. Prejudice and discrimination go together. Prejudice towards individuals is about self-hate and is related to identification and projection and is a learned behaviour (Giosetti, 1993). She argues that children are colour blind and learn to hate by observing adults. She notes that prejudice and its dynamics are similar in individuals as they are in nations. The need to project our failing (national) economies upon others leads to xenophobic utterings.

Social justice means that all institutions—structures as well as processes should be freely and equally accessible and available to all individuals, irrespective of their characteristics. Laws and legal institutions must ensure that equal opportunity be provided for education, learning, earning, and living. Social justice is the basis of equal and equitable distribution of resources and opportunities in which outside factors that categorize people are irrelevant. Although traditionally the term targeted poverty elimination, it has come to take on a wider meaning wherein social institutions have to take on a wider role to ensure equity of resources. It can be argued that all governments have a moral and ethical responsibility to ensure that all its citizens have equal rights, opportunities, and resources. In most countries around the globe, for example, categories of gender are not used for discrimination on a legal basis, but sexual orientation, race, and religion are often employed to base discrimination on.

According to Rawls (1971), social justice is about fairness. Justice also depends upon giving individuals capability, which in this case will be ‘capability to be healthy’. Rawls (1971) suggests fair equality of opportunity. Daniels (2012) criticizes Rawls for assuming that people are fully functional over a normal life span. The fair equality of opportunity account does not use the impact of disease or disability on welfare. Daniels (2012) points out that illness and disability (whether these are physical or mental or co-morbid may not lead to unhappiness, even if they restrict the range of opportunities offered to or are available to the individual.

Rawl’s theory of justice as fairness, according to Daniels (2012), was not designed to address issues of healthcare, as he assumed a completely healthy population and argued that any society which is purporting to be just must, therefore, assure that its members have equal basic liberties. Furthermore, society must not only provide a robust form of equal opportunity and limit inequalities to those who benefit and support the least advantaged. Social justice depends upon social reform. The principles of social justice work on individual, kinship, and population levels. The access to fair equality opportunity depends upon public education, early childhood interventions aimed at eliminating race or class disadvantages, and equality of opportunity. Whereas Daniels (2012) argues for an opportunity-based view, Sen (1992) recommends a capability-based approach. It is possible to include both to create a model which gives people both the opportunity and the capability to be healthy. Rawls (1971) view of justice is that of a liberal democratic political regime ensuring that its citizens’ basic needs for primary goods are met and that citizens have the means to make effective use of their liberties and opportunities. The second principle is to ensure that citizens have a fair equality of opportunity. This is particularly where individuals with mental illness tend to lose out. Principles of social justice rely on strengthening social institutions.

Social justice in relation to health in general (and mental health in particular) relies on the questions Daniels (2012) raised. The fundamental question is: what do we owe each other in the protection and promotion of health? He argues that there are three subsidiary questions: whether health should be seen as special; when are the health inequalities unjust; and how can we meet competing health needs in a fair and just way when the resources are finite? Healthcare ensures that individuals remain or become healthy in order to achieve their full potential and health, thus, ensures distinct (albeit limited) contribution to the protection of equality of opportunity. Daniels (2012) emphasizes that healthcare is of special moral importance because it helps to preserve our status as fully functioning citizens. Unlike food or shelter, healthcare needs may be disproportionate, thereby creating an inherent inequality and discrimination. As noted elsewhere, social determinants influence mental health and it is appropriate that social inequalities are tackled. However, more significantly, in order to ensure greater justice to health outcomes, the focus should not be only on the traditional health sector, but also on joined up thinking across education, employment, and the criminal justice system.

Health of the nations (including mental health) depends upon factors other than wealth, although wealth may be important. Culture, cultural values, government policies, social capital, social organizations, and social cohesion all play a role in determining health status. In countries around the world, there has been inadequate access to mental healthcare, for a number of reasons, including discriminatory constraints consequent upon stigma, keeping costs down and seeing mental health as purely secondary to physical health (Ozar & Sabin, 2012). Using the US as an example, these authors note that recent changes, such as vigorous (and better) advocacy, better understanding of mental disorders, more effective treatments, and the means to contain costs, have changed funding patterns.

Mental health funding consistently lags behind that allocated to physical health. This is related to stigma and discrimination, part of which is to do with not really understanding what mental illness represents. The range of mental illness, its varieties across the lifespan, and varying presentations all mean that funders are not able to decide what it being funded. Furthermore, conditions such as depression have been seen as a sign of personal or moral weakness, thus negating the seriousness of the condition. Substance use disorders are seen as self-induced and as a sign of a lack of backbone, thereby not deserving to be taken seriously. Mental health needs should be seen as basic health needs, and not meeting these needs should be recognized as a failure of fundamental social justice (Ozar & Sabin, 2012). Consistent advocacy and better recognition of the symptoms of mental illness have contributed to a degree of change in attitudes and knowledge, resulting in improved funding.

Social institutions, whether these are schools, universities, courts, or others, must be strengthened in the context of social justice in order to ensure delivery of social justice. The healthcare system should also be seen as an institution which must deliver social justice, not only in terms of proper accessible healthcare, but also preventive measures. Ruger (2010) offers ethical principles of human flourishing and these include: health capability, social choice on a dominance partial ordering of health capabilities, and relevant social decision-making; valuing central health capabilities, measuring inequalities, ethical commitment, and public moral norms; as well as to social determinants of health and joined up approach. What is worth bearing in mind is that at the core of social justice in health are also the ethical and moral frameworks. However, the key is also about getting the balance right between governmental responsibility and the individual’s choice and responsibility for their own health and capabilities.

Human flourishing is based on Aristotle’s theory. Ruger (2010) notes that ‘human flourishing’ is seen as the end of all political activity and what human beings are capable of. It is the basis of ‘good’, which is the aim of every action and decision (Irwin, 1999). It is also about the capability to function well if one so chooses (Nussbaum, 1990). For individuals with mental illness, this becomes a major issue in terms of the contrast between individuals’ expectations of their own functioning and that of the society at large. Another dimension that must be borne in mind is the one expressed by Ruger (2010) that there must be a distinction between achievement and the freedom to achieve. As Ruger (2010) goes on to explain, the capability to achieve valuable (but whose values and who defines them?) functioning also relies upon goods and circumstances needed to produce capabilities. As capabilities become assured, then it should be left to individuals to be free to make the choices they like (Nussbaum, 1990). In individuals with mental illness, there is a further tension in that different treatments or combinations of treatment may get them to a certain specific level of functioning, but their choices will depend upon a number of contextual factors. In theory these contexts must be the same for everyone in any given culture, but it is not true in actuality.

Ruger (2010) points out that the individual’s ability to function rather than actual resources should be the primary goal of public policy. However, in matters of health and healthcare, resources are the key in getting the individual to regain health and function as a fully active member of society. Thus, an evaluation of policy must explore how it (the policy) gives people (with mental illness) an opportunity to function fully and properly in society. Social justice equally applies to those who may not have mental illness. In addition, policy must focus on health. Health policy cannot be seen in isolation, as it has strong inter-connectedness with education, employment, the legal system, business, and other policies too.

Sen (1985, 1999) puts forward the theory of capability, which basically means that everyone should have the capability to lead a worthwhile life. Capability, according to Ruger (2010), can be related to well-being in two ways: first, it is a set of functions, such as the ability to feed oneself and walk unaided constitutes a person’s well-being; and second is the capability to accomplish these functions is their freedom to achieve personal well-being. Additionally, well-being depends upon the capability to function. There is no doubt that capability is also about human heterogeneity, and this is where individuals with mental illness and their capability (a) to achieve and maintain mental well-being and (b) to acquire full functioning of their mental and physical well-being come into play. Acknowledging heterogeneity provides a rationale for treating individuals differently under a health capability paradigm which needs to be developed further in that all individuals with mental illness are given equal status and support to ensure that they work at full capabilities. Ruger (2010) argues that the heterogeneity is also to do with positive freedoms. The focus is on achieving valuable functioning. However, in theory there is also a need to ascertain who defines valuable and whether such a definition includes capital values, individual values or societal/familial values.

The challenges for individuals with mental illness are many. These very much depend upon what the social expectations of the individual are. In capitalist and individualistic or ego-centric societies, these expectations will be very different. In such conditions, individuals are expected to look after themselves and their immediate families (largely nuclear), so the capability approach will have to focus on that; unlike socio-centric or collectivist societies, where capabilities must match the needs of the kinship or the extended family.

As noted above, health policy cannot be developed or seen in isolation, and therefore health indicators may need to be multi-dimensional too. Health rights in any given society are an important indicator in health policy. Yet very often these are ignored in many countries and cultures, being viewed as West-inspired interferences. Health capability must include equal access to healthcare when needed. There are various debates about how equal access is defined and described. For the purposes of this paper, it means being able to access good quality healthcare when needed without (undue) delay. Nobody who needs healthcare should be denied it, and policies must grant equal access to healthcare for all.

Social justice in the health context also means public education about mental illness, correcting false and harmful health norms. These have to be developed on a culturally relativist basis. There may be minimum criteria for some of the services, as described in this issue, but these have to be seen in and set in the norms context. This is where perhaps the capabilities approach may enable policy-makers to take individual needs and capabilities into account. Ruger (2010) argues that the health capability paradigm is an integrative model of disability, requiring respect for differences (thus also creating some difficulties for evaluation).

Barriers to good quality mental healthcare are many. Social discrimination is at the top of the list. These lead to poor economic investment in infrastructure, human resources, and training. Ignorance about mental illness feeds into this. Socio-cultural barriers may be another potential cause in affecting resource allocation. This unwittingly sets up a vicious circle where, due to a lack of resources, people seek care from alternative healthcare or faith-based practitioners; and policy-makers may see this as the preferred choice, thereby not funding the healthcare system properly. In countries with multiple cultural and ethnic groups and diversity, this may further create double jeopardy, thereby setting racial/ethnic prejudices in motion. Another point worth noting is the separation between physical and mental health in many countries, thereby creating difficult to overcome barriers.

Social justice and social discrimination go hand in hand. Social discrimination can be measured in several spheres, from personal to political ones. There is widespread discrimination in not giving proper habilitation to individuals with mental illness and not to give them voting rights, which means that they cannot stand for elections and, therefore, are excluded from participating actively in the political democratic process. In this issue, some of these areas are covered. For each of these papers, well-known policy-makers and parliamentarians have been invited to write commentaries. These commentaries indicate that policy-makers do understand the issues and are keen and committed to support this endeavour.

One of the major issues in the social discrimination agenda is the huge degree of variation in definitions used. Some countries use mental illness, others use mental disorder or mental derangement, whereas some use medically certified insane or medically proven total mental incapacity. Mental incompetence, insanity, lost his mind, demented, seriously weakened mental state, mentally deficient, insane or imbecile, certified to be insane, and mental ineptitude were some of the other terms used. Interestingly and equally frustratingly, these terms are often not described, and the interpretation is left to the person using them. The procedure for how a person is judged to have a mental health problem is not laid down in law. This leads to de jure and de facto discrimination. In many countries, the primary language is not English, so translation of the laws has been carried out. This may have left some gaps, in spite of careful translation and interpretation.

Political discrimination is rampant. The paper in this issue (Bhugra, 2016) shows that one-third of 193 countries studied show that people with mental illness are deprived of their right to vote. In only 11% of countries there is no restriction to vote. A similar proportion cannot vote if they have been detained under the law, and nearly a quarter are not allowed under the direction of the courts. Thus, for various reasons more than half of individuals are not able to vote, thus making a mockery of the democratic process. Furthermore, if they cannot vote they are not eligible to stand in elections, and thus for all practical purposes are excluded from the democratic political process. These variations also depend upon whether the country is high income or low income—the latter are much more likely to withhold voting rights.

For purposes of employment, one quarter of the countries surveyed do not define the term ‘disability’, and it is left open to interpretation. Two-thirds of the countries define disability to include mental illness, but one quarter have clear discriminatory laws against people with mental illness to enjoy protection in employment. In half the countries there are no explicit protections against dismissal/termination of employment/suspension from employment on grounds of mental health problems. One-third of the countries do not provide access to reasonable accommodation at the workplace with disabilities including mental disabilities. Thus, an example of good practice by BT, as shown in the paper Mental Health for Nations, stands out. Once again, high income countries come out better in this regard in comparison with low and middle income countries.

Personal discrimination (in terms of a right to property) is highly prevalent across the globe. A right of contract of persons with mental illness is recognized by only 21% of countries. More than one-third of the countries completely deny the right to contract to persons with mental illness. Once again, there are clear differences between high income countries and low and middle income countries. In spite of the fact that many countries have ratified the Convention of Rights of Persons with Disability, there appears to be a significant gap in delivering on this. Interestingly, 70% of countries allow people to have succession rights, and these too vary according to income levels of the country. Forty-three per cent of countries do not allow people with mental illness the right even to make a will! Persons with mental illness are discriminated in a significant number of countries around the globe with respect to the right to property. To complicate matters further, the right to inherit property and make a will are not an effective right. The right to marry and options of divorce on the basis of mental illness are both limited across many countries. Once more, one of the major problems in this context is the varying, unclear definitions, which are prone to mis-interpretation.

Discrimination against individuals with mental illness, thus, is widespread and much more common in low income countries, which in materialistic terms may make sense. However, major steps need to be taken to move this agenda forward. These discriminatory laws may well reflect underlying stigma against individuals with mental illness at a number of levels. There is no doubt that public attitudes to mental illness have varied from stigmatizing to accepting over a number of decades, especially varying among cultures. However, it must be remembered that positive attitudes do not lead to positive or more accepting behaviours. Teaching programmes certainly change knowledge about mental illness, but increased, improved, or better knowledge does not get rid of stigma against mental illness or individuals with mental illness. The challenge for policy-makers, clinicians, and individuals with mental illness is to attack discrimination using strategies similar to civil liberties, gender equality, sexual minority (LGBT) communities, which in many parts of the world have proven to be useful. It is important, therefore, that clinicians around the globe work with patients, their carers, and their families, as well as with relevant organizations representing these groups, to challenge discrimination, change laws, and ensure that these are applied equally. This equity must be enshrined in law for a number of measures, including funding for research, training, and healthcare delivery, as is the case for the physical health needs of the population. The challenges are, first, to ensure that laws change and, second, that accurate and regular reporting of these takes place and that these are monitored by impartial observers. There is simply no explanation for continuing discrimination against individuals with mental illness, their families, and those who care for them, whether they are professional or lay carers.

What next?

The psychiatric profession, in discussions with the society it serves, and the legal profession need to agree on definitions of terms so that they can be applied universally. A major part of this activity has to do with working across boundaries to understand what such terms mean and what the most undiscriminatory term is likely to be, and what its components should be. A first step may be for national associations to explore psychiatry’s contract with representative policy-makers, stakeholders, patients, their carers and families, and their groups. Psychiatry needs to know what the social expectations in such a contract are and, more importantly, through dialogue ascertain whether it is even possible to meet those expectations. For example, in many countries in the West, the chief role of the psychiatrist and the responsibility of psychiatry is about risk assessment and risk management only. The chief aim of exploring such an implicit contract is to ensure that both parties are aware of what is needed and what is required in terms of responsibility on each side. Psychiatry’s contract is also about adequate and indeed equitable funding for services as well as research. In many countries around the world, recruitment and retention into psychiatry are very poor. Some of it is related to status of the subject and some of it is associated with poor remuneration. In countries such as Norway, where psychiatrists are well paid, the numbers applying for posts is much larger. Psychiatrists expect services to be well funded and well-resourced. Each national association needs to take on the responsibility of clarifying the nature of the said contract. Psychiatrists as a profession need to address some of the challenges facing psychiatry. Apart from issues related to risk management and recruitment, a key challenge is the multi-dimensional nature of a profession which is in transition. The ongoing bitter, reductionist, internal battles between biological psychiatrists and social psychiatrists give a poor public impression of the profession. This feeds into stigma and discrimination against psychiatrists and psychiatry. Public/society expect psychiatrists to be healers, competent doctors, altruistic, moral, honest, trustworthy individuals who will promote mental health and can be a source of objective advice. In return, psychiatry expects from patients a degree of trust, autonomy, a role in public policy, advocacy, and financial as well as non-financial rewards. Psychiatry expects that the State will provide adequate resources, autonomy to the profession, and a value-laden equitable healthcare system. In return, the State expects that psychiatrists, as other doctors, will be competent, moral, honest, accountable, productive, and transparent, with clear objective advice. The public expects from the State a quality healthcare system which is accessible, equitable, and adequately resourced and funded and accountable. The State in turn expects from the public appropriate use of resources, some responsibility for their own health, and reasonable expectations. Psychiatrists as doctors also have a clear role, not only as healthcare professionals, but also as members of the public, who with their specialist skills can also act as advocates for the healthcare system as well as for the patients. As Bhui (2016) illustrates in this issue, social and political events form the discriminatory acts and policies so we need to be ever vigilant for our patients’ sake. He also highlights that discrimination affects individual’s mental health. Thus, the message has to be: discrimination is bad not only for your mental illness but also for your mental health as well.

The second key step is to create a Bill of Rights for individuals with mental illness. This appears in the paper in this volume as Health of Nations. Having demonstrated that discrimination is pervasive on a number of levels, it is imperative that the profession create a Bill of Rights which advocates not only for the elimination of discrimination but also encourages governments to give rights to patients which ensure their engagement and betterment on a number of levels. As Gupta, Methuen, and Kent (2016) show in this issue, income levels in a country also affect attitudes and acts related to prejudice and discrimination.

The third immediate step is to learn from examples of good clinical practice. As illustrated in the Mental Health for Nations, not only do we require minimum standards of care and service in many settings, we also need to look at good practice, which often is not very expensive and can make a huge difference.

Acknowledgements

I would like to thank the Executive Committee of the World Psychiatric Association. Thanks are due to Andrea Livingstone, Alex Smith, and Meg Chisholm for their ongoing support and advice. Thanks to the Centre for Mental Health Law in Pune and Dr Soumitra Pathare and his team for pulling data together, and to Dr Antonio Ventriglio, Dr Julio Torales, and Dr Susham Gupta for assistance. Andrea Livingstone as always did a sterling job, much appreciated. Albert Persaud unhesitatingly guided this project at many levels, thanks.