579824 research-article2015
ISP0010.1177/0020764015579824International Journal of Social PsychiatryVentriglio and Bhugra
E CAMDEN SCHIZOPH
Editorial
Social justice for the mentally ill Antonio Ventriglio1,2 and Dinesh Bhugra3 The poor outcomes in patients with mental illness need urgent attention at various levels in society. Mental illness can be disabling and may prevent individuals from participating fully in society and in social activities. The variation in physical health and mental health is seen globally, and variation in funding and resources between physical and mental health is often huge. Different health care systems deal with the discrepancy in different manners. There are very few settings where there is true integration between physical and mental health and between mental health and social care. It is difficult to be certain that the integration provides better outcomes for patients with mental illness. There is every possibility that human rights–based outcomes will actually improve the longterm outcomes of patients with mental illness. Furthermore, psychiatric disorders have a major underlying social factor in aetiology and also in management. Perceptions of the illness thus play a major role in stigma and help seeking.
Disjunction between physical and mental health There is increasing evidence that patients with mental illness are likely to die 10–15 years earlier than those who do not have mental illness (Chang et al., 2010; Harris & Barraclough, 1998; Khan, Faucett, Morrison, & Brown, 2013; Sims, 2001). As these authors suggest, the morbidity and burden of disease attributed to mental illness is way above that of cancer or heart disease, even though even in wealthy Western countries mental health does not attract the same levels of resources. Cultures determine health care systems and direct individuals to specific care pathways from the identification of experiences as abnormal or as symptoms and help seeking. It is quite possible that there may be delays in help seeking because where help is sought from depends upon the explanatory models of the individual and their families. For example, if an individual sees the illness as possession, they will go to a shaman or faith healer, and thus there may be a delay before they reach the professional sector. Over 40 years ago, it was demonstrated that between 70% and 90% of all illness episodes were treated in the folk or social sectors and only a small proportion reached professional health care (Zola, 1973). This may have been a reflection of the US health care system, but in many cultures, for a number of reasons, doctors are seen as the last point of contact. Thus, the patient journey needs to be understood
International Journal of Social Psychiatry 2015, Vol. 61(3) 213–214 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764015579824 isp.sagepub.com
in the societal context, as society responds to these abnormal experiences. Social justice is embedded within societies. It has a major role to play in delivering equality to access the basic necessities of life for all individuals in order for them to function fully. What does it mean? Sometimes social justice is confused with economic justice, but we see the two as completely different, and the latter forms part of the former. Justice itself is defined as a set of universal principles which guide people in judging what is right from wrong and is seen as one of the four cardinal virtues of classical moral philosophy (Center for Economic and Social Justice, 2015). Social justice guides individuals in creating institutions which provide what is good for the individual and society. Social justice inculcates personal responsibility and social responsibility for the betterment of society as a whole. Social justice and economic justice reflect what the patient needs and how their outcome and their recovery can be improved with that. How to use it? Social justice and its components, including human rights, can and should be used to change policies and attract sufficient and appropriate resources to deliver mental health care. Social justice has the advantage that it can be used in a culturally relativist way, depending upon societies, their social norms, values and attitudes. At a broader level, social justice is also about eliminating social inequalities which may cause mental illness. The way forward: Social justice can be used to deliver health justice where patients get the treatments they need, and these can deliver better outcomes. As Venkatapuram (2011) has highlighted, health (and indeed social) justice is about individual capabilities. Each individual has a right to have the capability to be healthy. The capabilities approach is an analytic evaluative framework for making interpersonal comparisons of well-being. Venkatapuram (2011) proposes that health (especially mental health) needs to be defined clearly, and he defines it as meta-capability. Thus, social justice can
1Department
of Mental Health, ASUR, Jesi (AN), Italy of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy 3Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK 2Department
Corresponding author: Dinesh Bhugra, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, PO 25, David Goldberg Centre, De Crespigny Park, London SE5 8AF, UK. Email: [email protected]
214 and indeed should be used to develop and encourage capabilities to be healthy across the entire population. Health and illness are inter-linked. It is critical that clinicians and policy makers give adequate appropriate support and response to social justice, and that is the only way inequalities leading to mental illness and outcomes will start to disappear. Although mental illness affects single individuals, it does also affect those around the individual who is experiencing it and may be suffering from it. Social justice is about equality and fairness. It also has both material and symbolic dimensions (Sheppard, 2002). In any group which experiences discrimination and resulting disadvantage, rates of mental illness have been shown to be higher and, equally importantly, individuals with mental illness are often discriminated against and require social justice to enable them to function at their desired capacity. Social justice equals fairness. Social justice has to balance the inequalities. Verhaegh, Hasel, and Becker (2011) argue that in rich countries with high levels of inequality, there can be low levels of mental health, whereas in poor countries where there may be more equality, there may be better mental health. Social justice cannot be divorced from human rights. Mental health is a social justice issue when individuals who are mentally ill are excluded from full participation in society. Poverty leads to mental illness (Manderscheid, 2013) through a number of variables such as physical and sexual abuse, psychological trauma, unhealthy lifestyles and neighbourhoods. Patients see food, employment, housing, income and high-quality service as their requirements (Rudnick et al., 2014), confirming an urgent need for social justice. Social justice and human dignity go hand in hand. References Center for Economic and Social Justice. (2015). Defining economic justice and social justice. Retrieved from http://www.
International Journal of Social Psychiatry 61(3) cesj.org/learn/definitions/defining-economic-justice-andsocial-justice/ Chang, C.-K., Hayes, R. D., Broadbent, M., Fernandes, A. C., Lee, W., Hotopf, M., & Stewart, R. (2010). All-cause mortality among people with serious mental illness (SMI), substance abuse disorders, and depressive disorders in southeast London: A cohort study. BMC Psychiatry, 10, 77. Harris, E. C., & Barraclough, B. (1998). Excess mortality of mental disorder. British Journal of Psychiatry, 173, 11–53. Khan, A., Faucett, J., Morrison, S., & Brown, W. A. (2013). Comparative mortality risk in adult patients with schizophrenia, depression, bipolar disorder, anxiety disorders, and attention-deficit/hyperactivity disorder participating in psychopharmacology clinical trials. JAMA Psychiatry, 70, 1091–1099. Manderscheid, R. (2013, June 25). Breaking the chains of mental illness that bind those in poverty. Behavioural Health Care. Retrieved from http://www.behavioral.net/blogs/ronmanderscheid/breaking-chains-mental-illness-bind-thosepoverty Rudnick, A., Montgomery, P., Coatsworth-Puspokey, R., Cohen, B., Fordruk, C., Lahey, P., ... Schofield, R. (2014). Perspectives of social justice among people living with mental illness and poverty: A qualitative study. Journal of Poverty and Social Justice, 22, 147–157. Sheppard, M. (2002). Mental health and social justice: Gender, race and psychological consequences of unfairness. British Journal of Social Work, 32, 779–797. Sims, A. (2001). Mortality statistics in psychiatry. British Journal of Psychiatry, 179, 477–478. Venkatapuram, S. C. (2011). Health justice. Cambridge, UK: Polity Press. Verhaegh, J., Hasel, R., & Becker, T. (2011). Social justice is pivotal to mental health care. Psychiatrische Praxis, 38. 38 - SD1. DOI: 10.1055/s-0031-1277865. Zola, I. K. (1973). Pathways to the doctor: From person to patient. Social Science and Medicine, 7, 677–689.
Copyright of International Journal of Social Psychiatry is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ISP0010.1177/0020764015579824International Journal of Social PsychiatryVentriglio and Bhugra
E CAMDEN SCHIZOPH
Editorial
Social justice for the mentally ill Antonio Ventriglio1,2 and Dinesh Bhugra3 The poor outcomes in patients with mental illness need urgent attention at various levels in society. Mental illness can be disabling and may prevent individuals from participating fully in society and in social activities. The variation in physical health and mental health is seen globally, and variation in funding and resources between physical and mental health is often huge. Different health care systems deal with the discrepancy in different manners. There are very few settings where there is true integration between physical and mental health and between mental health and social care. It is difficult to be certain that the integration provides better outcomes for patients with mental illness. There is every possibility that human rights–based outcomes will actually improve the longterm outcomes of patients with mental illness. Furthermore, psychiatric disorders have a major underlying social factor in aetiology and also in management. Perceptions of the illness thus play a major role in stigma and help seeking.
Disjunction between physical and mental health There is increasing evidence that patients with mental illness are likely to die 10–15 years earlier than those who do not have mental illness (Chang et al., 2010; Harris & Barraclough, 1998; Khan, Faucett, Morrison, & Brown, 2013; Sims, 2001). As these authors suggest, the morbidity and burden of disease attributed to mental illness is way above that of cancer or heart disease, even though even in wealthy Western countries mental health does not attract the same levels of resources. Cultures determine health care systems and direct individuals to specific care pathways from the identification of experiences as abnormal or as symptoms and help seeking. It is quite possible that there may be delays in help seeking because where help is sought from depends upon the explanatory models of the individual and their families. For example, if an individual sees the illness as possession, they will go to a shaman or faith healer, and thus there may be a delay before they reach the professional sector. Over 40 years ago, it was demonstrated that between 70% and 90% of all illness episodes were treated in the folk or social sectors and only a small proportion reached professional health care (Zola, 1973). This may have been a reflection of the US health care system, but in many cultures, for a number of reasons, doctors are seen as the last point of contact. Thus, the patient journey needs to be understood
International Journal of Social Psychiatry 2015, Vol. 61(3) 213–214 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764015579824 isp.sagepub.com
in the societal context, as society responds to these abnormal experiences. Social justice is embedded within societies. It has a major role to play in delivering equality to access the basic necessities of life for all individuals in order for them to function fully. What does it mean? Sometimes social justice is confused with economic justice, but we see the two as completely different, and the latter forms part of the former. Justice itself is defined as a set of universal principles which guide people in judging what is right from wrong and is seen as one of the four cardinal virtues of classical moral philosophy (Center for Economic and Social Justice, 2015). Social justice guides individuals in creating institutions which provide what is good for the individual and society. Social justice inculcates personal responsibility and social responsibility for the betterment of society as a whole. Social justice and economic justice reflect what the patient needs and how their outcome and their recovery can be improved with that. How to use it? Social justice and its components, including human rights, can and should be used to change policies and attract sufficient and appropriate resources to deliver mental health care. Social justice has the advantage that it can be used in a culturally relativist way, depending upon societies, their social norms, values and attitudes. At a broader level, social justice is also about eliminating social inequalities which may cause mental illness. The way forward: Social justice can be used to deliver health justice where patients get the treatments they need, and these can deliver better outcomes. As Venkatapuram (2011) has highlighted, health (and indeed social) justice is about individual capabilities. Each individual has a right to have the capability to be healthy. The capabilities approach is an analytic evaluative framework for making interpersonal comparisons of well-being. Venkatapuram (2011) proposes that health (especially mental health) needs to be defined clearly, and he defines it as meta-capability. Thus, social justice can
1Department
of Mental Health, ASUR, Jesi (AN), Italy of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy 3Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK 2Department
Corresponding author: Dinesh Bhugra, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, PO 25, David Goldberg Centre, De Crespigny Park, London SE5 8AF, UK. Email: [email protected]
214 and indeed should be used to develop and encourage capabilities to be healthy across the entire population. Health and illness are inter-linked. It is critical that clinicians and policy makers give adequate appropriate support and response to social justice, and that is the only way inequalities leading to mental illness and outcomes will start to disappear. Although mental illness affects single individuals, it does also affect those around the individual who is experiencing it and may be suffering from it. Social justice is about equality and fairness. It also has both material and symbolic dimensions (Sheppard, 2002). In any group which experiences discrimination and resulting disadvantage, rates of mental illness have been shown to be higher and, equally importantly, individuals with mental illness are often discriminated against and require social justice to enable them to function at their desired capacity. Social justice equals fairness. Social justice has to balance the inequalities. Verhaegh, Hasel, and Becker (2011) argue that in rich countries with high levels of inequality, there can be low levels of mental health, whereas in poor countries where there may be more equality, there may be better mental health. Social justice cannot be divorced from human rights. Mental health is a social justice issue when individuals who are mentally ill are excluded from full participation in society. Poverty leads to mental illness (Manderscheid, 2013) through a number of variables such as physical and sexual abuse, psychological trauma, unhealthy lifestyles and neighbourhoods. Patients see food, employment, housing, income and high-quality service as their requirements (Rudnick et al., 2014), confirming an urgent need for social justice. Social justice and human dignity go hand in hand. References Center for Economic and Social Justice. (2015). Defining economic justice and social justice. Retrieved from http://www.
International Journal of Social Psychiatry 61(3) cesj.org/learn/definitions/defining-economic-justice-andsocial-justice/ Chang, C.-K., Hayes, R. D., Broadbent, M., Fernandes, A. C., Lee, W., Hotopf, M., & Stewart, R. (2010). All-cause mortality among people with serious mental illness (SMI), substance abuse disorders, and depressive disorders in southeast London: A cohort study. BMC Psychiatry, 10, 77. Harris, E. C., & Barraclough, B. (1998). Excess mortality of mental disorder. British Journal of Psychiatry, 173, 11–53. Khan, A., Faucett, J., Morrison, S., & Brown, W. A. (2013). Comparative mortality risk in adult patients with schizophrenia, depression, bipolar disorder, anxiety disorders, and attention-deficit/hyperactivity disorder participating in psychopharmacology clinical trials. JAMA Psychiatry, 70, 1091–1099. Manderscheid, R. (2013, June 25). Breaking the chains of mental illness that bind those in poverty. Behavioural Health Care. Retrieved from http://www.behavioral.net/blogs/ronmanderscheid/breaking-chains-mental-illness-bind-thosepoverty Rudnick, A., Montgomery, P., Coatsworth-Puspokey, R., Cohen, B., Fordruk, C., Lahey, P., ... Schofield, R. (2014). Perspectives of social justice among people living with mental illness and poverty: A qualitative study. Journal of Poverty and Social Justice, 22, 147–157. Sheppard, M. (2002). Mental health and social justice: Gender, race and psychological consequences of unfairness. British Journal of Social Work, 32, 779–797. Sims, A. (2001). Mortality statistics in psychiatry. British Journal of Psychiatry, 179, 477–478. Venkatapuram, S. C. (2011). Health justice. Cambridge, UK: Polity Press. Verhaegh, J., Hasel, R., & Becker, T. (2011). Social justice is pivotal to mental health care. Psychiatrische Praxis, 38. 38 - SD1. DOI: 10.1055/s-0031-1277865. Zola, I. K. (1973). Pathways to the doctor: From person to patient. Social Science and Medicine, 7, 677–689.
Copyright of International Journal of Social Psychiatry is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
