From psychiatric patient to citizen revisited

It is nearly 20 years since Liz Sayce’s From Psychiatric Patient to Citizen: Overcoming Discrimination and Social Exclusion (Sayce 2000) was first published. Twenty years may not seem very long to some, but in the world of mental health a lot can happen in that time. Over those 20 years the political, social and economic citizenship of mental health service users and survivors has been promoted, contested and, most recently, denied. Sayce’s robustly evidenced and personally influenced exploration of discrimination and exclusion on grounds of mental health continues, updated and expanded in this new follow-up volume. In the preface to From Psychiatric Patient to Citizen Revisited, she writes that ‘madness and the fear of madness have featured through my life’ (xii). Sayce has first-hand knowledge of the book’s subject matter – not only madness itself, but the fear of all it entails and implies, including social discrimination and denial of citizenship. She also draws upon her experience and expertise as a highly regarded and influential leader in the UK service user, survivor and disability movements. Therefore, this book offers the reader deeper, and perhaps more credible, insights into mental health, stigma and discrimination than those written from purely academic or theoretical standpoints.

The basic crux of the argument is that stigma, discrimination and exclusion need a radical rethink in order to advance the equal citizenship of people living with mental health problems. Using research studies, statistics, policy, legislation and key informant interviews, the author builds a substantial body of evidence about the history, prevalence and nature of stigma and discrimination and the construction of different ideas about illness, danger and madness since deinstitutionalisation (when long-stay hospital patients were supposed to become community citizens). The book is largely about the United Kingdom, but the author draws on international sources and perspectives, including survivor activists such as Mary O’Hagan from New Zealand. Importantly, Sayce sets out the challenges and counter-arguments from the service user and survivor movements, privileging voices and positions that might otherwise be relegated to footnotes in conventional accounts or critiques of mental health policy – ‘voices of resistance and social change’ (20), as she puts it. As a result there is a clear focus on citizenship and human rights, social models, collective action, anti-discrimination work, participation, disability and welfare in the exploration of the operation of systemic power in discrimination and exclusion.

This book is one of Palgrave’s ‘Foundations of Mental Health Practice Series’, and it is very positive to see it published as part of a series aimed at those in practice or studying to be a mental health practitioner. The book gives a fundamental grounding in the politics of mental health and the reality of the lives of people who not only manage long-term mental health conditions, but live with discrimination, disablement and limits on their citizenship, and have actively resisted this. This grounding is vital for all those working or wanting to work in mental health services, no matter what the professional role, discipline or service. Complex and challenging ideas are explained in clear language, and the book structure allows readers to dip in and out, with more reading set out at the end of each chapter if they want to go further. Boxed examples and quotations give additional clarity to the implications of ideas or policies being discussed for practice, with the author encouraging readers to use what they have read to instigate change whatever their position in the mental health system. Training and education in mental health is still dominated by the medical model, focused on service delivery, policy implementation and administrative concerns. This book is essential reading for students in all mental health disciplines, as well as those doing disability studies, social policy and any social care or health qualification. In fact, it is essential reading for anyone with concerns about campaigning for equal citizenship for those living with mental distress.

Sayce opens From Psychiatric Patient to Citizen Revisited by acknowledging that ‘most people know something of the experience of exclusion through madness, or the fear of it – personally, from work colleagues, family or friends. People know it is hard to talk openly, without fear of being seen differently, treated less favourably’ (xii). She ends by concluding that ‘above all it is the large numbers of people living with mental health challenges and their allies with diverse talents, positions and sources of influence, who can be catalysts for change’ (164). During the current assault on the citizenship of people with mental health problems, service users, survivors and their allies continue to rise up to be those catalysts for change. From 16 March 2017, new Personal Independence Payment regulations were introduced that prevent the enhanced Personal Independence Payment mobility rate being awarded if someone cannot follow the route of a familiar journey without another person unless it was ‘for reasons other than psychological distress’. This means that people with serious ongoing mental health problems who experience overwhelming psychological distress when making journeys would only be entitled to a lower level of support, if any at all. RF, a woman living with long-term mental health problems, brought a legal case against the Secretary of State for Department of Work and Pensions challenging this regulation as discriminatory. On 21 December 2017, RF won on all three grounds of her challenge because the regulations discriminate against those with disabilities in breach of Human Rights Act 1998 obligations. In his judgment, Mr Justice Mostyn said:

I have explained above that the original policy intention was never explained to the outside world…It seems to me that the original policy intention, and the hypothesis, were tendentious, in the true sense of that word. The tendency being to save money. Plainly, the objective was to save money. (EWHC 3375 (Admin) 2017)

RF said, ‘This judgment is important for a community of people with mental health problems fighting for their lives against discrimination.’ At time of writing, the Secretary of State for Work and Pensions originally intended to appeal against the decision. But on 19 January 2018 the appeal was dropped, meaning that the Department for Work and Pensions will have to review benefits decisions for tens of thousands of eligible people. RF responded:

I am delighted to hear the Secretary of State has decided to honour the finding of the High Court that these regulations were ‘blatantly discriminatory’. I hope that future decisions will now be taken holding our human rights as central, so that no one else is put in a position where they have to either accept state discrimination or go to court over it. (Public Law Project 2018)

Sarah Carr
Department of Mental Health, Social Work and Integrative Medicine, Middlesex University London, London, UK
[email protected]
© 2018 Sarah Carr
https://doi.org/10.1080/09687599.2018.1443586