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Chapter 9 Discussion
Introduction
Inequality in mental health is a dimension of social justice that has tended to be overlooked, not least because of the complex patterns and trends involved and the multiple forces that impact on mental health. Drawing on a wide range of source material from research literature and reports of practice the working paper has aimed to make more visible the nature of mental health inequalities in Scotland and reveal how social identity can impact on mental health and well-being. The analysis not only adds to our collective understanding of how differences in mental health may be implicated in other sources of difference and disadvantage, it also illustrates and reinforces why mental health has to be a key component of both social justice and health improvement policies and strategies.
It is important to remember what we share: that is our common humanity, we are all human beings, and therefore 'are born free and equal in dignity and rights' ( UN Resolution, 1948). But, living in a social context we are distinguished by our class and socio-economic status and aspects of our social identities. What Chapters 4-8 demonstrate is the association between socio-economic disadvantage and discrimination and poorer mental health and well-being. What is also revealed is the impact of our social identities on the ways in which these sources of disadvantage and inequality are distributed, mediated, experienced and expressed, including the responsiveness and experience of services and health outcomes.
A lot is already being done in different ways to redress health inequalities, including mental health inequalities: through the social justice/Closing the Opportunity Gap agenda and associated equalities strategy, and through policies targeted specifically at health improvement/reducing health inequalities. This policy climate provides an important opportunity to speed up the momentum to address the causes and consequences of mental health inequalities, both across the population and as they impact on different groups. In addition, the legislative measures in place (see Chapter 2) provide a framework within which to tackle discrimination.
Social Justice, Equality and Diversity
The Scottish Executive Equality Strategy (2000a) draws attention to the different ways in which equalities is approached in policy terms including equal opportunities, social justice and diversity models.
It is not intended here to compare these different ways of thinking, but to consider how these models can contribute to identifying and tackling mental health inequality at different levels.
Level 1: At a population level a Social Justice approach identifies and targets the structural causes of poverty and injustice. Programmes targeted at child poverty, or educational attainment for example, can help to improve economic and social life chances with implications for improved mental health and well-being across generations. It also implies a role for services, including mental health services, in helping to address and redress mental health inequality.
Level 2: At the level of social identities, an equalities perspective recognises the differential impacts on specific groups of social and economic inequalities. For policies, services and practices this implies acknowledging that these structural inequalities may impact differently on the mental health and well-being of, for example, women, men, people from black and minority ethnic communities, people who are lesbian, gay, bisexual or transgender and people with disabilities. In addition, it implies consideration of the appropriateness, accessibility and cultural competence of services for different groups of people.
Level 3: At an individual level, a diversity perspective recognises and values difference. A pamphlet produced to promote Fair for All, the Scottish Executive/ NHSScotland strategy for eliminating discrimination and promoting equality of opportunity (Scottish Executive 2002a; Scottish Executive, 2004a) describes diversity as being about 'the recognition and valuing of difference … creating a culture and practices that recognise, respect, value and harness difference for the benefit of the patients, carers, members of the public and members of staff'. This implies developing practices that include, for example, an understanding of the importance for the individual of their sexual orientation and/or their cultural identity, but also the impact of racism, or homophobia on mental health and on the articulation or expression of mental distress.
Areas for Consideration
It is beyond the scope of this work to identify in any detail the implications for policy and practice that arise from the analysis. The following areas are highlighted as possible starting points to assist mapping out what needs to be done to address and redress mental health inequalities.
Understanding issues of identity
- Understanding differences and recognising areas of commonality across and within different social groups as they relate to mental heath inequality.
- Understanding the implications of multiple identity/multiple disadvantage on mental health and well-being.
Principles and policies
- Developing a set of core values and principles for addressing mental health inequalities.
- Identifying the priorities to tackle inequalities in mental health in Scotland over the coming five to 10 years, drawing on what we already know, collectively, about the key risk (and resilience) factors for mental health, about the nature of inequalities in mental health and about mainstreaming.
- Making more explicit the interconnections between policies to promote social justice and closing the opportunity gap and policies to promote mental health and well-being, to achieve common policy objectives.
- Using the social justice framework as an opportunity to extend the range of vision for mental health policy: considering the impact of priorities and interventions on the structural factors such as economic disadvantage that can be both cause and consequence of mental health inequalities.
- Ensuring that policies foster a practice environment that respects difference within a framework of common values.
Creating a supportive environment for practice
- Identifying the core competencies in service management and delivery required for inclusive practice that recognises and values diversity.
- Building partnerships and alliances, to be able to tap into and share expertise and learning across different groups and communities.
- Ensuring that commitment to evidence-based practice is allied with a commitment to values-based practice.
A theme throughout the report has been that responsibility for reducing mental health inequality includes, but extends beyond, mental health specific policies and practices to encompass the breadth of policies aimed at achieving social justice. As set out in Chapter 1, this implies a two-pronged approach:
- Mainstreaming mental health improvement goals in policies and practices aimed at achieving social justice/closing the opportunity gap, and in ways that reflect the unequal distribution of risk factors between social groups.
- Mainstreaming social justice and equalities objectives within mental health policies and services.
To achieve this requires action: at policy level across policy domains, as well as within mental health policy; operationally, across domains and within mental health specific initiatives; and at the level of practice. It requires both a population based social justice approach; an equalities perspective that recognises the different impacts for different social groups; and a diversity mind-set that recognises and respects individual difference and human rights. This is both the challenge and the imperative.
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