Speech by Trevor Phillips at the Sainsbury Centre for Mental Health, 7 May 2008
At the Equality and Human Rights Commission we often say that there are two challenges facing humanity - how we live with the planet and how we live with each other. How do we overcome the challenge of people eyeing each other warily over the fences of their differences?
We often think of those differences as largely physical - race, gender - or cultural, including differences or faith. But there are many other ways of dividing humanity against itself as we've learnt painfully over the centuries. But the story of social progress has really been one of the breaching of the frontiers that we erect between ourselves; and each time we break down some new barrier we are left wondering why we ever put it up in the first place.
I want, this afternoon, to explain why we see well-being and mental well-being, in particular, as a new frontier in the fight for social justice in the creation of a society which is fair; communities which offer the individual dignity and respect; the evolution of a people confident in their diversity.
Having had the opportunity to read a little about some of the work, and the voluminous research carried out by the Sainsbury Centre on the website, I feel privileged to be asked to speak to you on a topic of which I know very little.
I know that I know very little as for nearly three decades I have been married to a psychotherapist and writer, who is part of the great psychotherapeutic Cosa Nostra centred in the Tavistock Clinic - the Tavia if you like - and I am all too aware of how complex and rigorous the best work on mental health can be. I am grateful to the Sainsbury Centre for its contribution in this regard particularly for example work published in recent years on mental health and ethnicity, and mental health and gender.
Work like this will be a vital platform for the work of our new Commission, some of which is led by the board of our disability committee, which includes Liz Sayce from Radar.
Tackling the inequalities faced by people with mental health issues is among the many challenges faced by the Equality and Human Rights Commission. Angela has referred to the record of achieving social change by our forerunners - the Commission for Racial Equality, the Disability Rights Commission and the Equal Opportunities Commission. Over the last thirty years, they have between them made some kinds of prejudice utterly unacceptable in our society.
But as great as the changes in individual attitudes have been, it has become clear that many of the causes of inequality have persisted, leaving us with some stubborn gaps, for example, in pay between men and women, chronic underachievement of some ethnic groups, including some white children; and continuing discrimination and harassment against gay, lesbian and bisexual people.
All of these equality deficits are based on areas of human difference and identity of which we are slowly learning to accept need not define us as individuals completely, nor do they by themselves explain what our talents might be.
The fact that most professional child carers and primary school teachers are women does not mean that no man is capable of doing such jobs with distinction. The fact that most FTSE 100 board level executives are male clearly does not mean that all men are great business leaders, or that women are incapable of leading in tough commercial circumstances. Watching one hour of The Apprentice will put paid to both illusions.
And the fact that most Olympic level sprinters and world-class basketball players are of West African descent does not necessarily tell you that I should really have been a 200 metre gold medallist or have played for the New York Knicks (though actually here the stereotype sort of works - every four years I mildly regret the fact that I turned down an athletic scholarship to an American university in favour of studying chemistry here in London). But we know that as a society we still haven't removed the barriers that make the stereotypes more likely to be fulfilled than not.
That is why Parliament decided that the moment was right to create a new body to help us to tackle some of the structural inequalities that have resisted even the liberalised attitudes of the new century.
The new Commission carries all the mandates and most of the powers of the legacy Commissions. But we have new responsibilities including the promotion of human rights. In addition, we are the first British statutory body charged with securing greater equality and good relations in the spheres of age, sexual orientation and religion or belief.
We also have new powers. And we are one of three publicly funded bodies in UK law with a statutory guarantee of independence from government – the others being the Electoral Commission and the BBC. That guarantee is vital. It ensures that we are able to carry out our mandate to promote equality, human rights and good relations without fear or favour.
Britain’s social and economic landscape has changed radically over the decades. Alongside greater diversity, we have experienced greater wealth and economic opportunity. But richer has not always meant fairer.
And already we are finding that the diversity of our modern, multi faith, multiethnic society, in which women, disabled people, lesbian and gay people, old and young expect to be treated with respect and dignity, every day throws up real dilemmas of an astonishing variety.
In just one week, at the Commission – through our Helpline, our staff and Commissioners – we can be asked to offer our views, clarify the law or give guidance on subjects as various as the following:
- Should an employee have the right to demand their employers provide flexibility to allow them to care for an elderly relative? Consider the position of nearly five million women who thought they had got their children out of the door, to university or to jobs, and that they'd have the lives they promised themselves in their twenties. Now these same women have to fill the gap left by social services unable to keep pace with the expansion in demand and support their own parents as they get older
- Should a deaf couple with a deaf child be permitted to choose a deaf IVF embryo for their second child - or would that violate the child's human rights?
- Is it an act of unlawful discrimination to ask a potential employee if she is pregnant or plans to become pregnant?
- Is it a human right to wear the Christian cross or the Sikh Kara at work or at school?
- Is a person who is thought by his colleagues to be lesbian or gay, and is teased about it despite their protestation that they are actually heterosexual, a victim of unlawful harassment?
- Should a hospital or an education authority prioritise English translations rather than funding English classes for its users?
- Is there a case for a choice of legal jurisdiction in a multi-faith society thus allowing some people to choose to have their marriages, divorces or child custody cases decided by Islamic or Jewish law?
We want to work towards improving life chances for all and, by that, I mean the likelihood of an individual achieving a range of important outcomes across their life-cycle, from the start to the end of life. Our task is to narrow the gaps that leave some equipped to enjoy life’s opportunities and others facing the unrelenting struggle to get beyond the limits of their circumstances.
The vision of the Equality and Human Rights Commission is a society built on fairness and respect, with people confident in all aspects of their diversity. This lies at the heart of our effort to close some of the equality gaps which persist.
But after six months as Chair of our new Commission something else has become clear to me; there are some causes of inequality which we have not yet begun to tackle - either because we have only recently become aware of their significance - some discrimination associated with belonging to a particular faith group; or because they have become more important because of lifestyle or economic change – for example, two parent working and the longer life spans have increased the need for personal care both for the young and for the elderly.
Or sometimes it is because we have always known that the cause of inequality exists, but we have pushed it away from us, swept it under the carpet or pushed it up into the attic - we have done everything but faced it.
Despite its prevalence, mental distress is an aspect of our diversity we remain in denial about - to our great social and economic cost. It is probably still more difficult, in the 21st century, to 'come out' as having mental health issues than it was to reveal that you were gay or lesbian 30 years ago. It is hard to think of another common human characteristic that attracts the same type of fear and misunderstanding.
The World Health Organization has estimated that one person in four people in the world will suffer from a mental health problem at some point in their life. Common problems like depression affect up to one in six adults at any one time and GPs spend a third of their time on mental health issues.
Our failure to recognise and respond to this aspect of human diversity is perhaps nowhere more profoundly expressed than in the labour market.
Only 20% of people with mental health conditions work.
At one million people, the numbers on incapacity benefit for reasons of mental ill health outnumber the total number on job seekers allowance.
Someone who has been on Incapacity Benefit for more than two years is more likely to die or retire than get a job.
The Commission's Helpline is a good barometer for equality and human rights issues; and calls about mental health discrimination are not uncommon.
One woman with depression was being bullied at work to the point where she could not return to the workplace. However her employer refuses to make adjustments or investigate the behaviour of her colleagues until she can 'prove' she was being bullied, and until she provides a date for returning to work - which she feels unable to do without clarity on the adjustments they will make.
Another caller reported that he was not put on interesting projects, and told that he was no longer trusted because he had threatened suicide. After crying in a meeting, he was sent a letter informing him that this was considered unprofessional.
A man who experienced episodes of paranoia, psychosis and anxiety was 'interrogated' intrusively about his condition by his employer whose attitude became negative and hostile. They refused to agree to a reduction in his working hours and instead offered him a contract without regular employment benefits and rights, job security, or predictable hours, and low pay.
Fear of difference is perhaps nowhere as acute as in relation to mental ill-health. It is rare for bosses to say that they would not employ someone because of their race or gender; or even because of potential pregnancy. Yet more than four in ten employers say they would not recruit a person with a mental health problem. A survey by the Mental Health Foundation found that over half of mental health service users believed they had been turned down for a job because of their disability. Only a third were confident enough to disclose their condition on job application forms.
Employers are afraid to employ people with current or past experience of mental ill-health: ‘Will they be dangerous/inappropriate with customers or colleagues or will they “go mad at work”?’ People don't want to live next door to someone with mental health issues - only 29% say that they would feel comfortable if someone with schizophrenia moved in next door to them, with only 19% saying that they would feel comfortable about a person with schizophrenia marrying a close relative of theirs.
For many people, the experience of mental health problems seems to almost generate an exclusion zone around them. Friends, family, partners and workmates all fall away. Research has shown that people with more severe forms of mental illness have been found to have smaller social networks than others; and are far less likely to be married. So when people are at their most vulnerable they are also bereft of the social supports that make life liveable.
Stigma can be so powerful that it impedes performance. Studies have found when undertaking tests of intellectual performance, students whose psychiatric diagnosis was known to others in the group did worse than those whose mental health history was not disclosed. If the same impact applies in the workplace, we could be looking at a vicious spiral of stigma and underperformance.
We only need to look at some of our media. A Scottish study found that two thirds of newspaper and broadcast pieces about people with mental health issues depicted them as dangerous. In the UK as a whole, a review of newspapers found that 64% of mental health-related stories were negative as against 46% of articles about general medical issues. And 'negative articles about medicine tended to describe bad doctors, whereas negative articles on psychiatry tended to describe bad patients'.
At work, a recent survey by Depression Alliance found that around half their sample felt that they had been discouraged from taking on exciting projects; had been avoided by colleagues; had received snide comments; and had been passed over for promotion. Partly as result, only a quarter of people with depression informed their personnel departments of their condition.
But it's not that we want to shun people with mental health conditions completely. In 1995 a Mori poll found that the public was most likely to accept people with mental illness as road-sweepers, actors, comedians or farm workers; and least likely to accept them as doctors, child-minders, police officers or nurses. It seems mental health conditions co-exist in the public mind with the most menial and the most creative jobs – but not with jobs requiring responsibility.
So the message from some employers is: if you can’t keep quiet about the differences that mark you out, you’re mad to expect anything other than bad treatment. In essence, we are either recoiling from or punishing this particular form of difference at a time when we are accommodating and even embracing other kinds of difference.
All this seems strange to me in a country that is distinguished to its credit, by its tolerance of difference.
Our defining monarch, Elizabeth 1 set out the doctrine of toleration (thinking about religion), asserting, according to Sir Francis Bacon, that she would not open a window into men's souls - that is to say that this is a nation which would not judge people according to their faith, as long as they followed the rule of law and observed the common good. This lies at the heart of the live and let live philosophy that makes cities like London and Birmingham vibrant, multicultural places.
And when we get it right, British tolerance isn't some grim passive acceptance of difference. It is an active enjoyment of different food, music and ways of worship for example. And, at its finest, it is allied to a passion for justice that has become part of our culture, perhaps best summed up in the expression ‘standing up for the underdog’.
Our greatest playwright, William Shakespeare, wrote a famous speech which he put in the mouth of one of our most sturdy advocates of the British tradition of dissent, Sir Thomas More. More quells a London mob bent on violence against asylum seekers with these words:
Would you be pleased
To find a nation of such barbarous temper
That breaking out in hideous violence
Would not afford you an abode on earth....
...what would you think
To be thus used? This is the strangers' case,
And this your mountainish inhumanity
We have even made a national trait of the way we manage what we call eccentricity. We laugh at our own oddness, usually with affection. I often think about this in relation to migration in the context of accepting people’s difference. We can manage difference with humour.
Where would British humour be without our penchant for what John Cleese would call ‘silliness’? Or perhaps more accurately the line of humour that runs through the music hall burlesque of Dan Leno, surrealists like the Goons, the Pythons, the Goodies, and even more modern challenges to our sense of what's normal, like Eddie Izzard, Bill Bailey or, spectacularly, Little Britain? Basil Fawlty, or Benny Hill, in real life would probably have been put under a doctor's care long ago. Most of this kind of comedy puzzles other countries, or confirms that we, the British, are simply peculiar.
My point here is not to suggest that we should deal with stigma by laughing at mental illness. Rather I'd like to point out how selective we can be about what we find tolerable in the way of difference. Eccentricities of behaviour are in some circumstances acceptable in our daily lives if we can stop being afraid of them. In fact it seems as long as we can find the right context for difference we seem capable of working with all sorts of unusual things - of making reasonable adjustment for mental illness in much the same way we do for wheelchair users.
One of my colleagues, Baroness Jane Campbell recently returned from a visit to one of our ancient universities - it doesn't matter which, the story will stand for any of our top seats of learning. Whilst there, she had remarked on the range of bizarre practices which pass for tradition in such places; despite the fact that they are populated by many of the brightest people in our country. She was told that if, for example, a person finds it necessary to go everywhere accompanied by a goat and dressed as a shepherd- as is the case for one student - and neither goat nor shepherd costume interferes with his capacity to turn out world-beating work in, let us say, higher mathematics - well what does it matter to anyone else?
And let's be clear, this isn't just about indulgent traditions in elite institutions. I am going to be very careful what I say here, but I am a democrat, and my feeling is that when we, as a country, make a decision we are usually rational. So doesn't it say something important about our ability as a nation to look past the unconventional exterior, and to judge the true fitness of the individual for a job, that we have just handed the largest electoral mandate in Europe (other than in France) to someone that many clever people derided as a ‘tousle-haired dunderhead, apparently barely capable of doing up his own shoelaces, much less fulfilling the demands of high office’? You don't have to be a Conservative to have voted for Boris Johnson, to say that when we want to, we can judge a person on what we think they can do rather than what we think they might be. And we are right to do so.
Yet it is manifestly clear that we do not apply that same rational generosity to those who work with us, or who want to work with us, if there is a suspicion of mental illness in their background.
I am genuinely not being flippant here. I think that these are challenges from which we have turned away too long, except where the person concerned is wealthy, super-talented or powerful. In those circumstances, reasonable adjustment comes pretty easily to us.
But, in a Britain where we lose billions each year in workplace productivity because of mental illness, it must be time to recalibrate our understanding of whom and what we accommodate. Dealing with mental health issues can no longer remain a luxury for the few but must become the custom for the many. We cannot afford it to be otherwise.
And this is not just because we are losing hours when people are unable to work, or where the workplace does not present an environment that enables us to work. What we know now is that even for those who do not start with a disability, work itself is increasingly the environment that triggers mental illness.
Mental distress is joining conditions like back pain in becoming a modern industrial injury.
Work has always produced ill-health and disability. Just as the nature of work has changed, so the nature of the ill health and disability it produces has changed also.
But perhaps more critically, worklessness has a seriously detrimental effect on mental well-being.
Studies over the past 60 years have shown consistently that up to 40% of unemployed people suffer psychological distress. Over time, unemployment often leads to a loss of confidence, and a sense of being without any social value. Employment offers social networks, a route out of poverty, and a source of social status in market economies. The Sainsbury Centre’s own work on recovery acknowledges employment as a key priority. Work gives us identity, purpose and internal cohesion; Freud said it 'binds the individual to reality'. As 18th century poet William Cowper put it, ‘The absence of occupation is not rest, a mind quite vacant is a mind distressed’.
Suicide rates amongst the long term unemployed are 35 times higher than amongst the employed.
Systematic studies show the relationship between mental ill health and inequality. Professor Richard Wilkinson has demonstrated the clear relationship between unequal societies and stressed and unhappy societies. It should be seen as no coincidence that as the gap between rich and poor have widened in Britain, so the incidence of mental ill health has grown. This is why it is critical in thinking about equality in that we have an account not just of economic well-being, but account for and deal with the causes of inequality in relation to mental well-being.
Let me be as precise as I can be about this. Inequality does not make people ‘go mad’ as far as we know nor does being in work or being out of work by themselves. However we do know that all of these conditions in the right combination, and in relation to some kinds of people elevate the risks of mental illness.
For example we know that Pakistani women display double the rate of depression as do white women - 6.6% to 3.3%. We also know that they are more than twice as likely to be economically inactive.
What we can't be sure of is whether the inability to work, which often stems from not having English as a first language as much as it does from supposed cultural factors, is down to Pakistani heritage women being cooped up at home; or whether they are cooped up at home because of other factors and this in turn raises the risk of depression. My guess is that it's the first, but untrained intuition is a dangerous tool in this area. We need to study more and understand this better. But what we do know is that if we try to understand what is happening outside of this social context we may mistakenly apply largely medical solutions where we need social and economic remedies.
A similar point could be made about the prevalence of schizophrenia amongst African Caribbean men, which by the way costs the NHS in London alone some £100 million a year more than it should if there were no disproportion.
One point I thought about on the way here. We read yesterday about another young man stabbed on London’s streets. Gangs in these areas are ethnically defined. A hypothesis that many of us have pondered here is a specific cause of the ratcheting up of violence by kids who come from combat zones. Young people come here for good reasons. They come having seen brutality and torture and are asked to sit in class and behave like everyone else.
It is inconceivable this could work. Very few local authorities provide a psychotherapeutic bridge for these people. Not to blame young people but we need to think what we do to resolve this.
So, to summarise.
The modern workplace is producing mental ill-health; stigma and prejudice keeps people with mental health conditions outside the workforce; and worklessness is for many with mental health problems the single biggest barrier to recovery.
And second, though inequality, prejudice, and discrimination do not necessarily make you ill; removing inequality, prejudice and discrimination from our society could well make many people who are ill better.
Stopping this vicious cycle is not only in the interests of those with a mental health condition. It is in the interests of the nation.
The value from a single person working for a full year, rather than claiming benefits, is nearly £20,000 for the Exchequer and over £33,000 for the economy. Over an average person’s working life, this value could amount to over £530,000 for the Exchequer and nearly £900,000 for the economy. The cost to the economy of people with mental health problems being out of work is close to £10 billion per annum. The total cost to employers of mental ill health is estimated by the Sainsbury Centre at over £26 billion per annum.
The opportunity costs are even greater.
By shutting people with a mental health condition out, we turn our back on enormous talent and potential.
We know that Abraham Lincoln, Tolstoy, Keats, Van Gogh, Isaac Newton, Churchill, Dickens, Virginia Woolf, Ray Charles – our list could go on – Einstein, Hemmingway, all experienced mental distress. I could add that had their symptoms been a little more severe or long-lasting, we might have been deprived of the services of John Prescott and Alastair Campbell. And what if people had known about their problems?
Mr Bondevik of Norway was open about his mental health problems in office, secured the support of the Norwegian people and survived to be re-elected. Can we imagine the reaction here if a British Prime Minister publicly took a month off to recover from depression?
There are also many ordinary people with mental health problems succeeding in for example, jobs and in communities – but because many are afraid to be open we don’t know who they are.
Given all this, it is clear that the Government is right to raise expectations of people with mental health problems leaving Incapacity Benefit and moving into work, and critically not leaving work and going onto incapacity benefit in the first place.
But we need to up our game if we are going to make any real difference.
We have to challenge the growing stigma concerning the very people we are seeking to help. 'Lazy, fraudulent workshy scrounger wanted' is something you don’t see appear on job advertisements, yet that is the growing narrative concerning those on incapacity benefit. We can help create a positive narrative by focusing on individual potential which inspires both employers and potential employees. We need more people like Alistair Campbell, John Prescott and Stephen Fry to stand up and challenge attitudes to mental illness.
We must also redouble our efforts to support people not just to find jobs but to also develop and stay in jobs.
What does that mean in practice?
It means that we need to approach the issues of mental health at work not just from the point of view of a medical strategy. We also need an equality strategy.
One type of approach that has generated results is supported open employment, using job coaches to help people with mental health conditions find and retain work. About 50 per cent of people in supported work schemes gain paid jobs, against just 20 per cent in traditional sheltered (segregated) occupation programmes.
And we must match our efforts to improve employability with efforts to improve employer ability.
Individual employers need to be aware of the reasonable adjustments they could make to the workplace so that it is feasible for people with mental health issues to stay in employment. Perhaps, for good reasons, the disability movement, has tended to push for the tangible results brought by physical adaptations, adjustments and supports – and hasn’t had the same success in the largely neglected the less definable adjustments and support needed by people with mental health conditions.
The challenge of mental health is about social norms and behaviours; about new flexibilities and ways of doing things; about how we relate to one another; and about acceptance and mutual support.
For example, these may include:
• More frequent supervision than usual to give feedback and guidance on job performance
• Flexibility in work hours to attend healthcare appointments, or work when not impaired by medication
• A buddy/mentor scheme to provide support day to day
• Flexibility around sick leave, such as allowing the use of accrued paid and unpaid leave.
But policy makers have focused on creating programmes that work for people needing physical or technical adjustments or clearly defined physical support - but don't work for people with subtler, more fluctuating needs such as for example:
• Pathways to Work has been proven to be effective for people with physical impairments - but not for people with mental health problems
• Permitted work rules are not sufficiently flexible to account for the fluctuating nature of many mental health conditions
• Access to Work provides adaptations to ICT, travel (for example, taxis) and even structural adaptations like lifts - but it doesn't provide a temp to cover a job for the person with (say) bi-polar disorder who needs time off each year
• Direct payments can rightly provide someone with a significant physical impairment 24 hour personal assistance - so that they can pursue their life, employment and other areas. There is no record of this being on offer to someone with (say) severe schizophrenia, who with 24 hour support could organise their life, could do the very same. Direct payments are not benefiting mental health service users to the same degree as other disabled people.
We need a radical rethink about our employment policy and programmes and about how to create a workplace which cultivates openness, provides support and promotes mental well being.
In terms of permitted work, rather than only allowing someone to work 16 hours per week, why not allow people with fluctuating mental health conditions to annualise those hours to work when they can without losing their benefit entitlement?
Modern employers are transforming how we think of the workplace, taking advantage of new technologies to offer increasing flexibility in relation to when and where their employees work. Some are changing completely the contractual relationship between employer and employee - based around the delivery of objectives and projects, not job descriptions and hours worked. All these developments have the potential to open up opportunities for people who require historically atypical working arrangements. In our transformation of work programme we will identify, develop and promote such good practice to employers.
Our public services must continue to be reformed in order to put greater power and control in the hands of citizens, providing the practical support people need to lead their lives. At the Commission we are interested in the role individual budgets could play in empowering disabled people and people with mental health conditions to participate more fully in social and economic life. We will seek to influence the imminent debate around adult social care.
As a Commission we will take the lead in changing behaviour and attitudes by promoting awareness, supporting good practice and enforcing legislation. We will push for robust harassment and bullying policies, better staff training, better equal opportunities policies – push for workplaces which work for all workers.
We must start talking about mental health in order to open up about mental health. Being able to have this type of conversation is one of the reasons that the Equality and Human Rights Commission exists. Our role is to provide the space for people to express their differences and share their experiences; turning fear into empathy, self-awareness and compassion.
That is why, for example, we have launched our own YouTube channel with videos from a range of people explaining what makes them different and how it has affected their lives. I would encourage you all to take a look at our ‘Equally Different’ video clips on our website and YouTube. They are powerful personal stories from people with a diverse range of backgrounds.
Alongside contributions from sculptor Alison Lapper and actor Sanjeev Bhaskar, you will also find Colin Putney, who has OCD, talking about why he has to find moments in his life for peace and quiet, musician Amy Stretch Parker describes her bi-polar disorder and why she isn’t after a simple ‘cure’ and Chris McIvor, a survivor of the Boxing Day Tsunami, reveals the after effects - which have included depression. We deal in human difference. Most of us don’t meet people who are not like us very often. YouTube allows you to experience a life as someone else lives it.
The Commission has a major challenge ahead in creating a fairer Britain. It is clear to me that addressing both the causes of mental ill health and the barriers and discrimination people with mental illness experience is at the heart of that challenge. As a country, to fail to do so would be a kind of madness.