Why Parity of Esteem is Not Enough

This blog post was originally published at: http://www.huffingtonpost.co.uk/ed-pinkney/mental-health-parity-of-esteem_b_6183118.html

Mental health campaigners have been given cause for optimism recently thanks to increasing political discussion about underfunded mental health services. Whilst we can be thankful that such conversations are being entertained, there is cause to be wary of the rhetoric if we consider real implications to those at risk of mental health problems.

In 2011, the UK government published a mental health strategy which referred to the goal of giving “equal weight to both mental and physical health”. Others, including the Royal College of Psychiatrists, have talked about achieving “parity of esteem” between mental and physical health. These expressions may have captured public attention, but as an article published last week in the British Medical Journal pointed out, the phrasing is simple to the point of simplistic.

Any armchair philosopher can question the logic of the rhetoricians’ suggestion that the ‘mental’ is somehow distinct from the ‘physical’. To do so can be seen as uncharitable; pedantry that misses the point. Those using the expression would say that their aim is only to draw attention to the underfunding of mental health services; and with mental health services having been dangerously slashed, such efforts should be applauded and given full public support.

Having said that, while we engage in topical conversations about mental health, we must not allow ourselves to ignore symptoms of an underlying problem. Health services need to appreciate the deep interrelatedness of mental and physical health; at present they don’t, and the rhetoric doesn’t help.

The largest health burden facing the world this decade involves non-communicable diseases such as heart-disease, cancer, and diabetes. A better collective term is ‘stress-related disorders’, since they are all either caused by, or associated with, chronic stress (or lifestyle patterns related to chronic stress, such as smoking, unhealthy diets and alcohol consumption). Meanwhile, researchers are continuing to shed light on the gut-brain axis that shows how fundamental the links are between intestinal conditions and psychological health – and that’s before we get into comorbidity of mental and physical illness.

Modern medical science is increasingly revealing mental and physical health to not be separate yet interrelated domains, but rather two ways of viewing a single system. A health service that appreciated this wouldn’t encourage the idea that mental health services sit apart from other health services; it would do everything it could to strengthen pathways between the two, alongside a longer-term aim of embedding a consideration for mental health deep into every corner of the health service and every module of medical training.

Calling for mental health to be on an equal level with physical health doesn’t necessarily run counter to the aim of bringing mental and physical health services closer together. It can increase funding for mental health treatments. It can increase awareness of mental health at GP level. But it can also conjure up a combative image of mental and physical health as being in competition with one another, straining the already thin bonds between the two service areas. With a health system already under pressure, discord is the last thing needed.

That there should be wariness about bringing mental and physical health services closer together is understandable. The mind is a variable that’s hard to control for in medical studies. We just about manage to recognise its influence on the body with accounts of the placebo affect, but barely so. Going much further than this is scary; it draws us towards unchartered academic waters and requires us to traverse the borders between academic disciplines. Perhaps it also moves us towards a more preventative approach to health that might be seen as a threat to traditional institutional structures and finances.

In the field, it’s already being done. Encouragement can be taken from pragmatic examples like the use of cognitive-behavioural therapy in bowel disorders and social-prescribing in mental health (such as recommending forms of exercise for moderate depression). But these are still very much on the fringes. We need more of this kind of crossover at a strategic level; this whole-systems thinking that the World Health Organisation has been talking about, for 28 years already. We also need to look at alternative ways of categorising services.

The idea of dividing the mental and physical has deep roots, going back to Ancient Greece with Platonic ideas of conflicting poles and dichotomies. Perhaps the categorical thinking that gave rise to the ‘mind-body problem’ helped fuel Western progress and moved us ahead of the softer wholism of the East for half a millennia, but, right now, it threatens to stunt our health system.

So while the prospect of more funding for mental health services is a good thing, it’s no real victory if mental and physical services are not brought into unison. A health system that was in tune with medical science would have mental wellbeing at its core. But it would also see the body and mind as a single system. And, as with all systems, if you neglect one aspect then you affect the whole.

The cause of low mental health disclosure rates: "Fear of appearing weak" or poor publicity?

Yesterday, The Times Higher Education (THE) published an article suggesting that the low number of students and staff disclosing mental health problems could be explained by “a fear of appearing weak”. I’m not sure that’s a good explanation.

Firstly, the context — The article refers to a report from the Equality Challenge Unit (a charity that, according to its website, “works to further and support equality and diversity for staff and students in higher education”) highlighting that just 0.7% of students and 0.2% of staff are reporting a mental health problem. Even using conservative estimates about the prevalence of mental health problems, there is clearly a very significant number of students and staff that are not disclosing their condition.

The consensus is that stigma prevents disclosure, and that if people feel less stigmatised then the number reporting their conditions will grow. That may be true. But there’s a question in this discussion that needs more attention: Why should they disclose?

If the sector believes that students and staff will benefit from disclosing a mental health problem to their institution then they need to explain how. And it would follow that if the numbers still aren’t increasing then it’s because students and staff don’t think the advantages are significant enough. Or they still know nothing about them.

The ECU’s report states that students with a disability who access Disability Support Allowance don’t only benefit financially, but are also more likely to receive a first class or upper-second class degree. If institutions want more DSA uptake then they need to publicise this, and use it as a way of communicating the benefits of disclosure. They can start by addressing the issue of most students and staff not knowing that they would be entitled to DSA due to confusion around the use of the word ‘disability’. Or by developing, and making available to all staff and students, a university-wide mental health policy – as recommended in the Royal College of Psychiatrists’ report into student mental health.

Stigma is a part of this. But stigma should not be used by policy-makers as a way of shifting responsibility away from their role. If institutions want more of their members to disclose a mental health problem then it’s up to them to give good reasons for doing so. Gary Loke doesn’t seem to understand this:

Gary Loke, head of policy at the Equality Challenge Unit, said the survey showed that many people in the academy with mental illness were suffering in silence.

“If you do not disclose you have a problem, universities cannot help you,” he said. “Institutions are generally very supportive to disabled staff, but people need to feel they can come forward and talk about their mental health problems.”

You may mean well, Gary, but the bigger question to answer is this: how will universities help those that talk about their mental health problems? And what exactly do you mean when you say that institutions are “generally” very supportive? The burden of responsibility for low disclosure rates does not end with those that are not disclosing;  institutions must work on creating settings in which people feel inclined to disclose.