On 17 June 2018, Daniel Maughan and Hilary Caldicott spoke to us and answered questions on the topic of poverty and mental health. Daniel Maughan is consultant psychiatrist with Oxford Health NHS Trust, based at the Warneford Hospital, and Hilary Caldicott is a mental health service user who currently volunteers with Oxfordshire Mind’s Benefits for Better Mental Health service. In the 1990s, she was director of Oxfordshire Mind.
This summary brings together the key points that they made in their talks and that emerged from the discussion afterwards. You can also see Daniel Maughan’s slides here, and read Hilary Caldicott’s talk here.
The vicious cycle
The statistics show how poverty and mental illness form a vicious cycle. If you are born in poverty, you are more likely to develop mental illness. If you are in poverty and develop mental illness you are more likely to have a poorer outcome in your illness. The lower your income the higher the risk of developing anxiety and depression.
It’s also the case that severe mental illnesses such as bipolar disorder or schizophrenia contribute to a gradual downward socioeconomic trajectory. One of the main reasons for this is that many mental illnesses develop when people are teenagers or young adults, severely disrupting their education and knocking their life plans off course.
Welfare reform under the coalition and conservative governments has affected mental health service users particularly severely. The introduction of disability assessments by outside companies to determine entitlement to benefit and the changes to the non means-tested benefits supporting the extra costs of disability (the move from Disability Living Allowance to Personal Independence Payments) have meant many mental health service users either losing their benefits or having them significantly reduced. The high success rate of appeals against these decisions shows the extent to which the system is faulty. A recent high court ruling demonstrated that rules around PIP (specifically the exclusion of people with mental illness from the higher rate of mobility payments) was ‘blatantly discriminatory against those with mental health impairments.’ The government is not appealing the decision, and up to 150,000 people will have benefits reinstated (though a recent Moneybox programme exposed that there are no concrete plans for when this will happen.)
The poorest and most unwell people are carrying the highest risks of reforms that are dismantling the social safety net. The anxiety and distress caused by the faulty assessment system exacerbates mental health problems.
The importance of the social
There is increasing realisation that treating mental illness is as much a social challenge as it is biological and psychological. Strong social bonds, secure housing, lifelong learning and flexible routes into work are crucial to lifting people out of the vicious poverty/mental illness cycle. The NHS is gradually realising this – an example is the Oxford Mental Health Partnership, which brings the NHS mental health services together with charities like Mind and Restore, focusing on creating connections with the community. Battling against isolation, and fostering integration of mental health service users into the community is extremely important for building resilience. Self-stigma can be a particular barrier – Graham Thornicroft, Shunned: Discrimination Against People with Mental Illness (Oxford University Press 2006) is worth reading on the problem of self-stigma and the importance of integration and the development of a range of different social identities (e.g. as worker, member of faith community, parent, volunteer, as well as mental health service user.)
What could be called ‘social poverty’ is also a problem to be tackled: an absence of friends, people to share food with. Recovery depends not only on receiving an income, but also being part of the world, living an abundant life, and having hope-enhancing relationships (see Julie Repper and Rachel Perkins, Social Inclusion and Recovery: A Model For Mental Health Practice, 2003).
Spirituality, church communities and hope
Taking the spiritual dimension into account in treatment is important, without falling into the trap of imagining that all mental illnesses are essentially spiritual (a stance taken by some Christian groups in the US). Church communities, especially liberal ones, who are ready to embrace people of difference, can play an important role in social inclusion and encouraging hope. The newly established Oxford Centre for Spirituality and Wellbeing is making strides in this area.
Volunteering and recovery
The charitable sector is extremely important in supporting people with mental illness. Oxfordshire Mind’s Benefits for Better Mental Health service aids 750 people a year. Their benefits advisors are paid professionals, supported by volunteers who accompany and support people at assessments and other benefit-related meetings.
For people recovering from mental health problems, volunteering can be an important transition for building confidence; Mind has many mental health service users who are also volunteers, for example in the role of peer support workers.
Volunteering can play an important role in the Five Ways to Better Mental Health and Wellbeing:
- be active
- take notice
- keep learning
For people with severe mental health problems, and people in recovery, stable independent housing is very important. Mind has developed housing with support. Permanent supported housing is crucial for many, though currently unfashionable; such housing is usually only offered for 2 years.
The session concluded with the questions: Is the future more hopeful? Is our understanding of the links between poverty and mental health getting better?
In many ways austerity has meant a step backwards, though the persistence of mental health service users and the people who support them in striving for a better situation is a reason for hope. The Justice system (as shown in the high court ruling cited above) is also working to protect people from discrimination. Psychiatry itself has improved a lot and there’s been a prolonged revolution in learning how best to handle mental health. A new mental health law is on the cards, which promises to be more progressive than the current one.