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Prince Harry and the history of mental health stigma policy

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This week (8-14 May) is Mental Health Awareness Week, and mental health has been prominent in the news recently. In mid-April Prince Harry gave an interview promoting his charity Heads Together, which aims to eliminate mental health stigma, and promote talking about mental health. His widely covered remarks included: ‘It was only right to share my experiences to hope to encourage others to come forward and smash that stigma.’ Later that month it emerged that footballer Aaron Lennon was receiving treatment having been detained under mental health legislation. Finally, on 7 May, news broke that the Prime Minister, Theresa May was to announce her intention to scrap the Mental Health Act 1983 on the grounds that it fostered ‘discrimination’ and ‘unnecessary detention’, particularly concerning the disproportionate number of black people subject to its ‘sections’.

All these issues touch upon stigma in different ways: from people being encouraged to speak out about their difficulties, to mental health law being a part of potentially discriminatory practice. The drive to eliminate stigma from mental health diagnosis and treatment features in twentieth-century government policy at least back to the First World War. The two most influential strands in this effort over the last one hundred years have been to integrate mental and physical health, and to remove the legal system from mental healthcare.

During the First World War, the number of soldiers suffering from mental breakdown in service - now known as ‘shell-shock’ - brought the issue of stigma to the fore. At the time there were restrictions on the treatment of mental disorders: one could not be admitted as a ‘residential patient’ without having been legally certified. Cecil Harmsworth MP proposed the Mental Treatment Bill in 1915 to modify this rule, explicitly because – as the memorandum preceding the bill stated - ‘a sort of stigma attaches throughout life to a person who has once been certified as insane’. The Lancet’s (1915: 919-920) commentary on the Bill noted that it would be desirable to treat people ‘without putting upon them the stigma of legal insanity.’

The Bill ran out of Parliamentary time, but a seed had been sown. The issue of mental health stigma became the formal object of policy, and was combatted by downplaying the legal (certification) system in mental treatment. The British Medical Journal argued (1915: 869) that ‘[t]he patient who was certified carries a burden for the rest of his life’. In the 1920s the Macmillan Commission was set up, initially in response to concerns over wrongful detention. However, it ended up (in the Mental Treatment Act 1930) extending the provisions for ‘voluntary boarding’ – i.e. making residential mental treatment possible without legal certification. It also recommended that ‘the lunacy code should be re-cast so that the treatment of mental disorder should approximate as nearly to the treatment of physical ailments’ as possible, and also that ‘certification should be the last resort and not a necessary preliminary to treatment’ (British Journal of Nursing (1926): 200). Thus, by the 1930s the removal of the stigma of legal certification and the aspiration for equivalence between mental and physical health were established objects for mental health policy.

In 1946 the National Health Service Act brought mental health within the comprehensive health service. Integration was seen as progressive and destigmatizing, although it wasn’t total. The Percy Commission on mental illness was then set up in the 1950s, again ostensibly around concerns over wrongful detention. Its 1957 report contained the clearest statement yet that psychiatry should become integrated with ‘general medicine’: ‘disorders of the mind are illnesses which need medical treatment... most people are coming to regard mental illness and disability in much the same way as physical illness and disability’ (this statement could easily be from a pamphlet in the early 2000s).

However, by the time the Mental Health Act 1983 was passed, formal policy had moved away from concerns about stigma: the issue was now the rights of people who had been compulsorily detained to contest this detention. The Mental Health Act Commission was established with a duty to monitor and inspect the proper application of ‘formal sections’ (i.e. compulsory treatment). The displacement of the integrationist agenda in policy terms continues to be in evidence in the late 1990s with Labour’s National Service Framework for Mental Health (1999). This recommended that urban mental healthcare be provided by ‘single-speciality mental health trusts’, a sharp division between mental and general medicine. An article in the British Journal of Psychiatry argued in 2003 (183: 5) that this was ‘likely to perpetuate the stigma of mental illness’. Regardless, single-speciality trusts were again championed in a 2007 Department of Health Annual Report.

Thus mental health stigma became less an explicit object of government policy; the Mental Health Act 2007 focused heavily on establishing the grounds for compulsory treatment rather than battling stigma. Anti-stigma efforts were left to ‘third sector’ organizations such as mental health charities (though still supported by the Department of Health). By the 2010s, this had become intertwined with a culture of celebrity endorsement (notably in the UK by actor and comedian Stephen Fry, for example). This is the context in which the Duke and Duchess of Cambridge and Prince Harry, with their Heads Together charity, are now operating.

In healthcare policy terms, this has coincided with a more locally-focused approach, replacing Labour’s more centralized strategy. In one sense, the Health and Social Care Act 2012 mirrored the NHS Act of 1946, as it contained explicit mention of mental alongside physical health. Otherwise the delegation of control to local Clinical Commissioning Groups stands in stark contrast to the centralization of the NHS’s birth. This policy aims to enable flexible local provision (given, for example, the concentration of psychosis in urban areas). However, it drastically reduces the potential for systematic, centralized anti-stigma efforts. Given mental healthcare’s history as a ‘soft target’ for cuts, central safeguards are arguably necessary.

The comparison of physical and mental health is on the agenda (post-2012) through campaigns promoting ‘parity of esteem between mental and physical health.’ This aims to eliminate stigma, not through promoting the integration of state-provided health services, but by focusing upon attitudes and ‘esteem’. This is undoubtedly the cheaper option. The repeal of the 1983 Act announced this weekend could also be read in that light - when Theresa May rails against ‘unnecessary detention’, it is difficult to avoid concerns that this might mean reducing inpatient provision. As activists have stressed, whilst the 1983 Act has its problems, the most pressing problem in mental health at the moment is lack of funding.

During the twentieth century anti-stigma policy in mental health has been two-pronged: integrating mental and physical healthcare, and reducing the role of the legal system in mental healthcare. From the 1980s onwards however, governments have moved away from this approach. Policy is now more heavily reliant on charity campaigns targeting ‘attitudes’ and ‘esteem’ rather than centrally-mandated administrative and legal changes to the provision of healthcare. The welcome stress in public debates on destigmatisation runs the risk of obscuring the actual direction of policy: towards local patchworks of services, balkanization of mental from physical healthcare, and austerity-driven reductions in provision.

Please note: Views expressed are those of the author.


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