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This essay will firstly define what discrimination is and what it means to discriminate. Examples will be used to demonstrate what discrimination may look like. A definition of empowerment will also be used. The essay will then critically explore theory and ideas around power and how power manifests between groups. This part of the essay will touch on the idea of ‘othering’. The essay will move on to focus on mental health, ‘race’ and racism. The essay will use the idea that ‘mental illness’ is a social construct and look at how ‘mental illness’ can be open to influences of racism from society (Bailey 2004). The essay will make links to institutional racism in mental health and psychiatry.
In a basic sense to discriminate means to: “differentiate” or to “recognise a distinction” (Oxford Dictionaries 2012). In this basic sense it is a part of daily life to discriminate. For example, a baby will often discriminate between a stranger and their caregiver. Discrimination becomes a problem when the ‘difference’ or ‘recognised distinction’ is used for the basis of unfair treatment or exclusion (Thompson 2012). Anti-discriminatory practice in social work concerns itself with discrimination that has negative outcomes; whether this is ‘negative discrimination’ or ‘positive discrimination’. Both are equally as damaging.
Thompson (1998) defines discrimination as a process where individuals are divided into particular social groups with an uneven distribution of power, resources, opportunities and even rights. Discrimination is not always intentional (Thompson 2009) and there are various types of discrimination (EHRC 2012). Discrimination can be direct, indirect, based on perception or on association (EHRC 2012). The Equality Act 2010 is legislation that protects individuals and groups against discrimination. The Equality Act 2010 brought together several pieces of legislation to protect several ‘protected characteristics’: age, disability, gender reassignment, marriage and civil partnership, race, religion or belief, sex and sexual orientation. Discrimination does not just occur on a personal level, according to Thompson (2012), discrimination occurs on three levels; personal, cultural and structure. This will be explored more later on.
‘Empowerment’ is a term that often comes in to play when examining discrimination; therefore it is important to have an understanding of both. Empowerment is the capacity of individuals or groups to take control of their circumstance and use their power to “help themselves and others to maximise the quality of their lives” (Adams 2008: xvi). Empowerment is then not an absence of discrimination and power but an individual’s capacity to own or share that power and take control. Therefore empowerment is an anti-oppressive practice not an anti-discriminatory one. They are linked but not the same.
Social workers act as ‘mediators’ between service users and the state. Social workers are in a role that can potentially empower or oppress (Thompson 1997). For this reason Thompson (1997: 11) argues that “good practice must be anti-discriminatory practice”, no matter how high the standards of practice are in other respects (Thompson 2012). Thompson (1997) reminds the reader many times throughout his book that “If you’re not part of the solution you are part of the problem”. I choose to include this because it reinforces that social workers need to challenge discrimination and take action against it. Discrimination is political, sociological and psychological (Thompson 2012). To ‘accept’ and tolerate it and to not to challenge it does indeed make social workers part of the problem. Discrimination has links with power which the essay will move on to explain next.
As defined by the Oxford Dictionary (2012) power is “the ability or capacity to do something; the capacity or ability to act in a particular way to direct or influence the behaviour of others or the course of events; or physical strength or force exerted by someone”. From this definition power could be seen as a coercive force or authoritarian. However, some theorists would argue that there is more to power than just coercion and authority. Parsons (1969 cited Rogers 2008) took a different view on power. He saw power as a way of maintaining social order instead of a force for individual gain (Rogers 2008).
Parsons (1969 cited Rogers 2008) believed that to be able to enforce coercive action and justify it, there needs to be a collective interest from the social system as a whole (Rogers 2008). Lukes (1974) would disagree with Parsons definition on power. Lukes argues that power is less abstract (Rogers 2008) and that exercising power is the decision to exert control. Lukes (1974:74) illustrates this point as: “A exercises power over B when A effects B in a manner contrary to B’s interests”. Dominelli (2008) focuses more on the idea of competing power; which group has more power than the ‘other’. This splits people to either be in the dominant group or the minority. A dominant group tends to be deemed superior, and with superiority comes privilege (Dominelli 2008). As a result the other group is deemed inferior, the minority and disadvantaged. It is this compound of dominance and oppression that discrimination derives from (Rogers 2008). It is a groups perceived superiorly over another group (Thompson 2012) that ‘justifies’ coercive action, control and discrimination.
When people form oppressive relationships the tendency is to make a strategic decision that excludes a particular group or individuals from accessing power and resources (Dominelli 2002). ‘Othering’ can be experienced as multiple; multiple oppression. People can be ‘othered’ simultaneously due to a number of social divisions (Domenelli 2002), for example, being a black woman who experiences mental health issues.
Social workers need to recognise power and its links to discrimination. Not to could further oppress (Thompson 2012). It can feel uncomfortable to be in the privileged position; whether this is as a white person or a man and so on. The ‘privileged group’ need to engage in the fight for equality (Corneau and Stergiopoulos 2012). White people need to engage with the fight against racism and accept responsibility for racism as it is a problem of white society and therefore involves white people (Strawbridge cited Corneau and Stergiopoulos 2012). This explanation can be applied to any other groups that are considered to be the ‘other’.
Rogers and Pilgrim (2006: 15) suggest that superiority is a social construction: a “product of human activity”. Dominelli (2002) goes further to say that oppression itself is a social construct as oppressive relations are not pre-determined but they are reproduced between social interactions and routines. Language is often used as a key part of social interaction and is also a very powerful tool. This relates heavily to social work as social workers are responsible for writing reports/care plans/assessments. Depending on how social workers word written pieces of work can indeed paint a very different picture of the service user they are working with. I was once told that ‘words are the bullets of prejudice’, this illustrates that labels and language can be powerful, damaging, potentially discriminatory and oppressive.
Although labels can be damaging they are a part of social interaction. Labels help us to construct our social world and we use them to find similarities and differences to process the world around us (Moncrieffe and Eyben 2007). Although the process of labelling is “fundamental to human behaviour and interaction” (Moncrieffe and Eyben 2007:19) social workers need to be aware of when these labels have the potential to be damaging, oppressive and rein forcers of discrimination. Social workers need to reflect and consider what labels they give people and what impacts this may have. Labels can be used to change or sustain power relations which can have an impact on prejudice and on achieving equality (Moncrieffe and Eyben 2007).
This essay will use the themes discussed so far to focus in on mental health as an area of practice and critically explore institutionalised racism within mental health practice and psychiatry. To begin I will briefly return to Thompson’s (2012) PCS analysis in relation to mental health and ‘race’. The ‘P’ level is our own individual attitudes and feelings (Thompson 2012). Although it is important to examine our own beliefs we do not live in a “moral and political vacuum” (Coppock and Dunn 2010: 8). For this reason Thompson (2012) also refers to the cultural (C) and structural (S). ‘P’ is embedded in ‘C’ and ‘C’ and ‘P’ in ‘S’ which builds up interlocking layers of discrimination; personal, cultural and structural.
The ‘C’ level is where we learn our norms and values. Individuals learn these values and norms through the process of socialisation which occurs through social institutions such as the family, religion and the media (Haralambos and Holborn 2008). These institutions can produce ideas about what is considered ‘normal’ or ‘right’ (Coppock and Dunn 2010). From this it is not surprising that there is an attitude in society that people who experience mental health issues are violent and a danger to society; even though there is no relationship between mental health and violence (Rogers and Pilgrim 2006). However, the general media uses terms like ‘psycho’ (Ward 2012) or ‘crazed gunman’ (Perrie 2011) in relation to acts of violence creates prejudice. This prejudice can then be used to discriminate. For example, a community may not want a ‘mental home’ to open near them as ‘the mental people’ will cause a threat to their community.
The ‘S’ level is the level of institutional oppression and discrimination. Ideas that Thompson (2012: 34) refers to as being “‘sewn in’ to the fabric of society”. Western psychiatry is laden with cultural values and assumptions that are based on western culture (Coppock and Dunn 2010). This suggests that western and white is ‘normality’ and anything that deviates from this is ‘abnormal’ (Corneau and Stergiopoulos 2012), or as previously discussed; ‘other’. It is the ‘C’ and ‘S’ level which the essay will focus on more.
Institutional racism explains how institutional structures, systems and the process embedded in society and structures that promote racial inequality (Jones 1997). It is considered to be the “collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin” (MacPherson 1999). Jones (cited Marlow and Loveday 2000: 30) goes further than this definition to also include “laws, customs, and practices which systematically reflect and produce racial inequalities”. Institutional racism is believed to be a more subtle and covert type of racism (Bhui 2002) and often said to be unintentional (Griffith et al 2007).
BME groups are differently represented in psychiatry (Sashidharan 2001). People of African-Caribbean heritage are over represented yet people of Asian heritage underrepresented in mental health settings (Sashidharan 2001). As BME groups deviate from the ‘white norms’ they appear to receive either too much attention or too little (Sashidharan 2001). This would suggest that the systems which operate within psychiatry are institutionally racist.
Both ‘race’ and ‘mental illness’ are social constructs (Thompson 1997; Bailey 2004). Thompson (1997) argues that despite the lack in biological evidence for the explanation of racial categories it is still a widely common way of thinking. Bailey (2004) argues that ‘mental illness’ has always been a social construct therefore open to racism and other forms of discrimination. The declassification of homosexuality in the Diagnostic and Statistical Manual of Mental Disorders (DSM) illustrates Bailey’s (2004) point.
‘Race’ immediately brings up issues around power and the relationship between what is seen as ‘natural’ and ‘social’ (Westwood 2002). Historically ‘it was viewed that inequalities around ‘race’ had a ‘natural’ explanation (Westwood 2002). ‘Race’ could be traced back to anthological tradition (Rogers 2006; Craig et al 2012) and colonial discourse with the belief that white identity is superior (Westwood 2002) and that black people are “lacking civilisation”, “savages” and a “subhuman species” (Bailey 2004: 408-409). According to Bailey (2004: 408) “the effects of racism on psychiatry can be directly linked to the early stereotypes about black people arising from pseudoscientific racism”. It is this pseudoscience racism (science which lacks scientific method or evidence) that underpins racism in mental health services today (Bailey 2004).
Racism has many different sides and is a multidimensional form of oppression and discrimination (Corneau and Stergiopoulos 2012; Thompson 2012). Racism is widely known to be the cause of disparities in health and mental health (McKenzie in Bhui 2002; Griffith et al 2007; Craig et al 2012). BME individuals find themselves navigating their way through a system that works from the dominant discourse of the ‘medical model’ (Corneau and Stergiopoulos 2012). This allows a small amount of room for different and alternative frameworks to challenge racism which is already ingrained in the system.
To illustrate this point I will use an example from my practice. I work with a black woman who experiences mental health issues. She has spiritual beliefs and usually openly takes about her beliefs at home. She fears one resident as he is very religious and she feels that he has ‘special powers’. I supported her to an appointment with her psychiatrist as she had begun to feel mentally unwell. He did not enquire about any social, cultural or structural factors that may impact on her mental health. I tried to advocate the experiences she had shared with me and reiterated what she was saying. However, he advised her that the ‘tugging’ she experienced in her stomach was physical and to see a doctor and increased her anti-psychotic medication. Her spiritual experiences were not validated, he individualised the ’cause’ of her ‘illness’ and used a medical intervention.
Western psychiatry tends to separate the mind from the body and spirit (Bailey 2004). According to Bailey (2004) many BME service users find this approach “unhelpful and irrelevant to their experiences of mental distress”. This is because for many BME the mind, body and spirit work in union and the feelings and behaviours behind this is woven into people’s wider existence (Bailey 2004). Kortmann (2010) believes that these types of clinical intervention are often ineffective due to service users non-western origin and tend to quit treatments earlier. For example, some African cultures can believe that seizures are cause by evil spirits (Kortmann 2010) and therefore do not take medication prescribed as they do not believe it to be an illness.
Westwood (2002) writes that the negative impact of racism can have a significant impact on an individual’s mental health. However in a recent piece of research Ayalon and Gum (2011) concluded that black older adults experienced the highest amount of discriminatory events but there was a weaker association with this and experiences of mental health issues. To account for this it was concluded that BME groups experienced more events of discrimination over their life course and as a result have become more resilient to it (Ayalon and Gum 2011).
Some writers argue that to construct institutional racism as the explanation to the disparities in mental health can add to the debate and effectively alienate BME groups even further (Singh and Burns 2006). Singh and Burn (2006) state that, the accusation of racism within psychiatry will give service users the expectation that they will receive a poorer service and this will encourage service users to disengage with services or offer voluntary admission. What Singh and Burn (2006) are speculating is presented by Livingstone (2012) as self-stigma; the stigma that is present on an individual level rather than on a cultural or social. It is the stigma that is internalised that can prevent people from access services (Livingstone 2012) and thus, actively discriminating against one’s self. Therefore, Singh and Burns (2006) argue that individuals to stay away from needed services until it is too late and there are few alternatives but to detain them and enforce treatment.
Although Singh and Burn (2006) make a logical point they fail to recognise BME service user experiences of Mental Health Services. Bowl (2007) conducted a qualitative research to gain the views and experiences of South Asian service users as most literature is through the lens of academics and professionals. The experiences of this South Asian group would certainly suggest the presence of institutional racism within Mental health Services. The main areas identified were their dissatisfaction in not being understood in the assessment process due to language barriers and cultural incompetence (Bowl 2007). This misunderstanding led to misdiagnosis and refusal of services (Bowl 2007).
Racism is often not the only form of oppression that people face. Disadvantage can occur from several areas (Marlow and Loveday 2000). BME groups experiencing mental health issues are already subjected to multiple oppression. There is not enough words in this essay to explore this further but wanted to acknowledge that forms of oppression are not experienced in isolation of each other. For example, links have been made between individual’s lower socio-economic status and experience of mental health issues and how black people can face the added stress of earning less and experiencing higher levels of unemployment (Chakraborty and McKenzie 2002). This begins to illustrate the complexity and how oppression is inextricably intertwined.
Institutional racism has been highlight in a number of Inquiries in practice. It was firstly highlighted in the Stephen Lawrence Report in 1999; a black young person who was murdered in a racist attack and yet again in the David Bennett Inquiry in 2003; a black man who died in 1998 after being restrained faced down by several nurses for nearly half an hour. Lord Laming (2003) also identified issues around racism in his Inquiry into the death of Victoria Climbie. There is not enough words to go into any of these inquiries in any detail but they have been included to demonstrate institutional racism in practice in the police, mental health service and social work.
It may seem that whilst mental health services operate within the medical model that is catered towards the white majority things will not change. Institutions and systems are indeed difficult to change, however social workers can work with service users to empower, advocate, challenge and expose discrimination in services and bring about social change.
Empowerment is complex in general but becomes more complex in relation to ‘race’ and ethnicity (Thompson 2007). Social workers need to firstly be aware of institutional racism before they are able to challenge it (Thompson 2007). For social workers to challenge institutional racism they need to challenge policies that do not address the needs of BME groups. To do this, social workers need to be aware of the complex power relations and deeply ingrained racist patterns in society (Thompson 2007).
In my practice in a mental health setting I have contact with medical professionals and often support services users to appointments. I find that I must hold onto my social work values and not get drawn into the medical model way of working but to remain holistic in my approach.
To conclude, this essay has demonstrated that discrimination is far more complex than treating someone differently. It has focused on a more subtle, covert and indirect form of discrimination: institutional racism. The essay has examined the links between discrimination, racism and power and introduced the idea that ‘mental illness’ and ‘race’ are both social constructs. It is this subtle and covert form of discrimination that can be damaging. It can be hard to recognise as it is woven into the very fabric of society (Thompson 2012). However, the message in this essay is that social workers need to recognise power relations, how they operate, on what level they operate at and to challenge discrimination (anti-discriminatory practice) and work with service user to empower them to overcome these obstacles (anti-oppressive practice). Social workers must ‘swim against the tide’ and not collude with these attitudes no matter how deeply ingrained and embedded they are in society. For the social workers that fail to do so will ultimately become part of the problem.
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