Linda Dunion explores why attitudes towards mental health issues north and south of the border are so different
In early July, evidence of a growing north-south divide emerged from the Department of Health in England. Cross-border comparisons seldom slip unnoticed beneath the media radar. As a rule, the press is fascinated by the differences, for good or ill, between Scotland and our nearest neighbour. Whether they are a source of shame, pride or puzzlement, they normally get our attention. When, as in this case, research surfaces to indicate that people in Scotland compare favourably to our southern counterparts, it does not usually end up in the non-story bin as it did this time. Media neglect of the story does not, however, alter the fact that attitudes towards mental ill health in Scotland seem to be improving as those in England get worse.
Yet in England, as in Scotland, mental health issues are governmental priorities. And for good reason: the Sainsbury Centre for Mental Health has estimated that mental health problems cost the UK over £77bn a year. The Scottish Association for Mental Health (SAMH) puts the cost to Scotland at £8.6bn, or 9 per cent of GDP. The economic, social and personal costs of mental ill health have spurred government to act to improve mental health, and tackle the discrimination and exclusion that too often go hand in hand with a diagnosis.
Our potential to achieve and maintain good mental health is determined partly by our genes, partly by how we are parented at the start of our lives and partly by environmental factors. We cannot vaccinate against mental ill health but we can invest in personal and public strategies to minimise the risks. Reducing poverty, tackling discrimination, improving diet, supporting good parenting, reducing isolation, raising housing standards, increasing community safety and investing in green spaces and the built environment all help support good mental health and wellbeing.
Even so, mental health problems cannot be prevented entirely. Currently one in four of us will experience mental ill health. If we do not, we will know a family member, friend, colleague or neighbour who will. In spite of this, we are still not good at talking about our mental wellbeing, and our attitudes towards people who experience mental ill health, particularly the more serious illnesses, like schizophrenia and bipolar disorder (or manic depression) are often rooted in misunderstanding and prejudice rather than reality.
| DIFFERENT COMPONENTS OF THE NATIONAL PROGRAMME |
| National Programme for Improving Mental Health and Well being |
Breathing Space Helpline
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Choose Life – suicide prevention
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Headsup Scotland – children and young people project
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‘see me’ – national anti-stigma campaign
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NHS Health Scotland – mental health first aid training & mental health
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Healthy Working Lives – workplace mental health
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Scottish Recovery Network – promoting and supporting recovery
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Well? – National programme magazine
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Well? – What do you think? – National public attitudes survey
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There are, however, signs that in Scotland this is beginning to change. Surveys commissioned in 2002 and 2004 by the Scottish Executive’s national Programme for Improving Mental Health and Well being found evidence of a shift in attitudes for the better. With the 2006 research due out later this month, there are grounds for optimism.
In Scotland and in England, there appears to be a high degree of understanding and acceptance about mental health problems. Both the national Programme and Department of Health surveys show that most of us think that anyone can become mentally unwell (97 per cent in Scotland, 89 per cent in England). However, when presented with statements designed to dig below the surface, the veneer of tolerance begins to look pretty thin in places.
Questions on danger, violence and public risk show that the public in England have become more fearful and less tolerant than their Scottish counterparts
Questions on danger, violence and public risk show that the public in England have become more fearful and less tolerant than their Scottish counterparts 
. Between 2002 and 2004, there was a decrease of 17 per cent, from 32 per cent to 15 per cent, in the percentage of Scots who believe people with mental health problems are often dangerous. In England by comparison, this rose from 29 per cent in 2003 to 34 per cent in 2007. In 2004 a quarter of Scots thought that the public should be better protected from people with mental health problems, compared to 37 per cent responding to a similar question in the English survey.
Negative perceptions lead to discrimination and to people expecting to be stigmatised. Unemployment rates for people with long-term mental health problems, at around 80 per cent, are twice as high as for disabled people as a whole. This has less to do with the abilities of people with experience of mental ill health and more to do with discriminatory attitudes among employers and the general public. In Scotland, ‘see me’ found that while 88 per cent of working age adults thought that someone with a history of mental ill health could hold down a job as a cleaner or a labourer, less than half thought they could be a nurse, a managing director or a bank manager.
The fear factor referred to earlier is probably behind the finding that only one in three people in Scotland and around one in five in England feels that being a childminder or a babysitter is a suitable job for someone who’s had mental health problems. It is not uncommon for people to mistakenly believe that paedophilia is a kind of mental illness. Bruce from Castle Douglas has borne the brunt of this misguided belief. He told ‘see me’, “It’s ridiculous really – they call me a paedophile, which is really insulting as I most definitely am not one. I’ve even had bricks thrown at my window.” Such extreme behaviour is thankfully rare.
Less rare are the low-level, hurtful behaviours that lead to people being shunned, ridiculed, overlooked or belittled. Yet, even here, things are starting to improve. In the report, ‘A Fairer Future’, launched in June, ‘see me’ published the results of its first major survey of stigma and discrimination from the perspective of people with direct experience of mental ill health and those closest to them. With over 1200 voluntary responses from across Scotland, the survey is one of the largest of its kind internationally. It was designed to find out if people in Scotland were behaving better to those affected by mental ill health than they did when the campaign launched in October 2002.
Improvements in individual experiences of stigma and discrimination were reported by 42 per cent of respondents. However, 46 per cent could not see any difference and 11 per cent said that it had got worse for them personally. Progress is being made but not fast enough. However, 70 per cent felt that the problem of stigma had reduced in society as a whole in Scotland and 80 per cent now found it easier to be open and talk about their mental ill health.
Being open is not easy and the impact of ‘self-stigma’ can be profound. An earlier ‘see me’ survey found that 43 per cent had not applied for a job because of how their mental health history might be perceived, while 57 per cent had concealed past or current mental health problems when applying for a job, and one in three believed that they had been denied a job they were qualified for. The Fairer Future survey found that between 2002 and 2006, 82 per cent of respondents stated that they had acted differently, possibly avoiding a situation because they were worried about other people’s reactions.
Danny from Ayr has taken on more than his share of the myths around schizophrenia. “I would love to go out more places such as the local pub and library but I am too frightened to in case I am dangerous. I have never been dangerous but you read about schizophrenics being dangerous all the time in the paper, so I thought that because I have schizophrenia that I would be dangerous if I went out.”
The gap between public attitudes in Scotland and England are not down to some geographical quirk or inherently different national characteristics. They reflect differences in approach taken by the Department of Health and the Scottish Executive. In 2001, the Scottish Executive earmarked £4m of tobacco windfall tax to a new national Programme for Improving Mental Health and Wellbeing. With suicide, depression, stigma and mental health promotion among the issues to be addressed, the National Programme was designed to take mental health issues out of their NHS box into the daily lives of the Scottish public. It has provided strategic leadership and resources, and fostered collaboration between the various organisations and agencies involved.
The level of funding for such an ambitious programme, at around £4m per annum, was not high for the scale of the challenge. Reducing suicide rates, combating deep-seated fears and misconceptions, promoting a recovery model, developing training and building a sound evidence base on mental health and wellbeing have been just some of the components funded to good effect.
While the investment has been relatively modest, the amount of activity generated at both national and local levels is anything but. The fact that the Executive chose to take a fairly relaxed view of how the programme should be delivered has been key to its success. It accepted the need to have different models and activities to address different issues. The main stipulation has been to operate on the basis of the best available evidence of what works in suicide reduction, tackling stigma, addressing depression or improving public awareness and understanding.
The result has been a busy family of highly focused and motivated organisations and agencies. Far from being a dysfunctional assortment of competing siblings, those of us involved talk regularly, work in each other’s best interests and make a genuine effort to co-operate on the ground. Some,like Choose Life and Breathing Space, have been encompassed within the Executive or one of its agencies, others like ‘see me’ and the Scottish Recovery network have their own independent, voluntary sector-led management groups. All operate both nationally and locally, generating a great deal of noise about mental health issues that has penetrated the public consciousness. With the advent of Vox, a Scottish-wide service user organisation, and a growing range of widely available training courses on mental health and ill health, this noise is set to get even louder.
The size and complexity of the country is probably one reason why England has not adopted a similarly joined-up approach. But a lack of integrated effort is not the only explanation for the north-south divide in attitudes. Funding is one of them. At 16.5 pence per head of population, annual investment in changing attitudes in Scotland, through the ‘see me’ campaign dwarfs Department of Health spending of less than 2 pence per head on ‘Shift’, the English equivalent. In July an alliance of English charities, frustrated at the lack of government funding for a high profile anti-stigma campaign, won a total of £18 million from the Big Lottery and Comic Relief to develop ‘Moving People’, an England-wide campaign, modelled on ‘see me’ and Like Minds Like Mine in new Zealand.
The negative drift in English attitudes will be a priority for Moving People. The consortium of charities behind the bid is well aware that the under-funding of the past is only part of the problem. The new mental health act in England, with its emphasis on public risk and security has been controversial, with media coverage fuelling public fears. This reflects a wider problem with the media, which other campaigns have successfully addressed: the need to stop demonising or ridiculing people because of their mental ill health. Most (not quite all) of the Scottish media, both national and regional, now avoid offensive language, misleading portrayals and inflammatory coverage. They have kicked the habit of running mental health stories without comment from people directly affected. Too many in the English-based media have yet to be persuaded to mind their language on mental ill health.
The fact that attitudes in Scotland have improved is no accident. It is down to political will, investment by government and popular support. The national Programme has provided focus and leadership, and ‘see me’ has acted as a catalyst for national and local anti-stigma action. The media in Scotland can take its share of the credit for improving public attitudes through better quality reporting, made easier by the willingness of growing numbers of people prepared to talk to them about their experiences of mental ill health.
It would be premature to conclude that the tide has turned irreversibly. The results to date are encouraging but fragile. A spate of high profile press stories, linking mental illness and violent crime could set back attitudes towards public safety. The priority now is to consolidate the gains made already
so that they withstand the inevitable challenges that will arise. That is a task for all sectors of Scottish society, not just those for whom mental health is the day job.
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