DURING THE presidential election campaign, there was much talk about mental health issues. However, debate should not simply focus on services and their problems.
In a recent study, commissioned by Amnesty International, researchers from DCU found that people with mental health problems in Ireland suffer high levels of discrimination and prejudice in their communities. Mental health is a human rights as well as a clinical issue. Different individuals and groups in the field of mental health have very different assumptions and priorities. We propose a “citizenship agenda” as a way of creating unity of purpose.
The word “citizen” refers to someone who participates fully in the society of which he/she is a member, benefiting from the rights and carrying the responsibilities of that society. Citizens only forfeit certain rights if they contravene the laws of their society. But many psychiatric patients have lived with a diminished sense of their own citizenship even though they have not committed any crime. This has been manifested in very many ways, including:
Violence:A UK survey of 778 service users found that 47 per cent had suffered physical attack at some point in their lives.
Restricted parenting rights: This ranges from programmes of forced sterilisation (in the last century) to unwarranted questioning of parenting skills.
Social exclusion and discrimination: Mental health service users endure much higher rates of unemployment compared with the rest of the community.
B Medical personnel sometimes do not take the medical problems of mental health service users seriously, delaying the diagnosis of serious illnesses. Life expectancy of the mentally ill is at least 20 per cent less than that of the population in many developed countries.
Complaints to criminal justice system:These are frequently not taken seriously if the person complaining is known to have a mental health problem.
Exclusion from society: Although the old asylums are now being closed, exclusion from society continues in many other ways, such as opposition to planning for new community-based residential units. Service users frequently maintain that discrimination and exclusion from society are bigger problems than the issues that brought them to mental health services in the first place.
As full citizens, mental health service users are entitled to the best medical care and support services, with clear information about treatment risks and benefits. They are also entitled to jobs, adequate housing, proper physical healthcare and freedom from discrimination. This is the “passive” dimension of citizenship, involving entitlement and equality.
However, there is another aspect of citizenship and mental health that is largely unexplored in current debates: a more positive, “active” dimension involving the right to define oneself and to celebrate a different identity. Growing numbers of mental health service users are rejecting the traditional language of psychiatry.
Groups such as the Hearing Voices Network, Mad Pride and Mind Freedom argue for the validity of different ways of framing their experiences, rather than simply as symptoms and signs of illness.
This “active” dimension presents a substantial challenge to professionals. They must develop the ability to question their models, diagnostic categories and therapies, and to engage in dialogue with service users and groups who are seeking a less biomedical understanding of mental illness. They will need to engage critically with their own professional backgrounds in order to redefine the relationship between professions such as medicine and the struggles of those who endure states of madness, distress and alienation.
Promoting the citizenship of people who use mental health services would be a very welcome role for our new President. But any campaign about citizenship will have to pay due regard to both active and passive modes of citizenship. The President could provide a unifying force in this, and help bring about the implementation of the government's mental health strategy, A Vision for Change.
Dr Pat Bracken is clinical director of mental health services in west Cork
Dr Joan Giller is an area medical officer in community services in west Cork
Dr Terry Lynch is a medical doctor, psychotherapist and author in Limerick