Making space for everyone’s mental health

I am Sahaj Kamra. Before joining the Communities and Priority Groups team at See Me, I thought mental health stigma and discrimination were experienced similarly and equally by everyone, but that isn’t quite the case. At See Me, we are continually discussing and beginning to better understand how the intersections of power and marginalisation (such as can be experienced by those discriminated against on the basis of protected characteristics) and/or wider societal adversity can create distinct disadvantages for different groups.

Systems of power and marginalisation include racism, homophobia and sexism, for example. Adversities may include substance use, trauma and poverty. These interconnected and overlapping systems create and uphold inequalities in mental health support and outcomes. An example of this is that Black people are more likely than white people to be detained in hospital, due to being perceived as a risk to themselves and others (Mental Welfare Commission, 2021). The stigmatisation of multiple facets of identity and adversities can combine to create unique experiences for individuals and groups.

As a national programme, See Me is on a deliberate journey laid out in our current strategy With Fairness in Mind to better understand these distinct experiences as they relate to mental health stigma and discrimination. We are doing this by working in partnership with communities experiencing multiple marginalisation using asset-based community development approaches. We want to co-produce solutions, building on the strengths, skills, knowledge and expertise that exists within our diverse communities.

Internally to the programme, See Me are engaging in critical reflection, learning, development and knowledge exchange sessions, and participating in training with expert equalities organisations. Our most recent focus has been to understand intersectionality, which has been supported by Glasgow Women’s library and The Collective.

See Me’s learning and research partner The Mental Health Foundation has also produced an evidence review on intersectionality in the context of mental health stigma and discrimination, which will support See Me to better understand and apply an intersectional approach across its work, from priority setting to research, campaigns and community engagement.

See Me has supported targeted work within communities for a number of years, collaborating with organisations such as LGBT Health and Wellbeing and Feniks, and administering an Anti-Stigma Arts Fund which prioritises projects led by or meaningfully engaging with multiply marginalised groups. We have recently renewed our focus on understanding racialisation as it relates to mental health stigma and discrimination for distinct groups, such as young people. We have been working with partners such as the InRen Network, the ILFA project, and the West of Scotland Regional Equality Council and are adapting our engagement practices and learning materials and resources as a result of learning from them.  

Our partnership working and recent training experiences have clearly reemphasised that mainstream institutions (of which See Me is a part) and services can marginalise by default and re-produce inequalities when there is not a deliberate effort to disrupt the status quo. In a mental health context, available support or community engagement methods may be suitable for some but not accommodate the needs of others by recognising diverse understanding of mental health or wider contexts of marginalisation. For example, some racialised groups experience greater exposure to stressful events such as micro aggressions, overt discrimination and financial burdens, which directly affects people’s mental health.

Mental health stigma is produced and upheld at various levels in society, from individual attitudes and behaviours to institutional policies and practices, which can then be internalised by individuals and produce feelings of inferiority. Some identities and experiences can be valued more highly than others (white, male, able-bodied, heterosexual etc.), which can lead to systematic discrediting of groups through harmful stereotypes (e.g. the ‘hysterical woman’). This compounds the stigma experienced related to mental health.

There is an historic tendency in service design to go for the ‘low hanging branches’, adopting approaches which cater well to some populations (generally those valued most highly by the system) the “mainstream”. This leaves out the voices and experiences of many marginalised groups and these groups in turn are labelled “hard to reach”. This process is exclusionary and deliberate efforts are then needed for active inclusion of these groups.

To counter this approach, it is important to think about the ‘furthest away branch’ (those multiply marginalised/harmed populations).The assumption is then, that if you can reach this branch, you will catch every other branch on the way (The Collective training on Intersectionality in Practice, June 2023). Just as Kimberlé Crenshaw in her ‘Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Anti-discrimination Doctrine, Feminist Theory and Antiracist Politics’ in 1989 has emphasised, in reference to those seeking to eliminate racism and sexism:

“If their efforts instead began with addressing the needs and problems of those who are most disadvantaged and with restructuring and remaking the world where necessary, then others who are singularly disadvantaged would also benefit” (p.167).

This demonstrates that an intersectional approach is needed to dismantle and distribute power in a way that improves lives of the most disadvantaged in our society.

Cultural backgrounds also influence the experiences of mental health stigma at the individual and group levels. For example: the words we use to express mental health and stigmatisation can vary greatly, and so can associations we have with our mental health. Personally, coming from a non-western background, mental health was more about spiritual health for me. Spirituality cannot be separated from mental health for many groups. It becomes important then, not to consider mental health, or associated stigma, in isolation from all the wider social, political and cultural factors a person is situated within in order to design interventions to address mental health stigma and discrimination.

In many settings, wellbeing is the word which resonates more with communities than mental health, and we have been told by a range of partners that using the words mental health can hold associations which can cause harm, such as for some Minoritised Ethnic groups. Another reason for emphasising this cultural appropriateness is that communities have told us that where individuals and groups feel alienated by terminology, they may be excluded from genuine participation.

The learning here for See Me and others is that we need to be flexible to incorporate a broad range of knowledge and understandings of stigma and discrimination into our work and build trust to collaborate closely with communities to genuinely understand these issues from a range of perspectives, rather than dismiss certain words and experiences as out of scope.

In recent partnership discussions, we have invited critical reflection of our own definitions of mental health stigma and discrimination and encouraged people to add words they use to talk about feeling stigmatised.

One of our partner organisations working with diverse ethnic communities (their own preferred term) emphasised the role of faith and spirituality within the communities they work with:

“When working with the communities we usually ignore the context that is very important to them. In the West, it is forgotten that faith is enmeshed in some communities and groups but is often ignored and scientific terms are given predominance which does not resonate. Mental health is over medicalised and the role of spirituality in working with the communities is not considered. Cultural understanding is very important to come up with coping mechanisms for all communities” [Johannes Gonani, Pachedu].

Conversations with our partners relating the experiences of a service user have broadened our understandings of how even well-meaning support and interventions can leave some groups out by design. The following anecdote relating to an experience of foodbanks highlights this:

“A service user explained her interaction with a food bank… [she] was told that you can be supported by the food banks and she got the Swede vegetable from there. And then she said “I am not sure if I am supposed to eat it or display it.” The food banks can either provide culturally appropriate food and the other way can be to conduct cooking classes to teach people how to make that vegetable. It generates a feeling of “I cannot even feed myself.” It exacerbates the feeling of isolation.”

This example works as a metaphor for how existing mental health support is not always culturally appropriate to all, and therefore doesn’t support the needs of many groups. As a result, mental health and support services can be viewed as “perceived western concepts”. When people do not relate to it, they are unable to get the support they need and it further exacerbates the situation.

See Me acknowledges that we need much more nuanced and in-depth understandings of the contextual factors in which mental health stigma and discrimination are produced and a broader frame which incorporates differences in definitions as well as centring diverse lived experiences of mental health. We must also consider the role of our institutions in upholding the systems of power and marginalisation in our society and work to transform our own cultures and systems to actively embed anti-discriminatory systems, policies, cultures and practices.