Everybody hurts? Privilege in mental health.

I’ve seen a lot of discussion lately – most recently this morning on Twitter, regarding the footballer Stan Collymore – as to whether celebrities who are open about mental distress are a) wonderful ambassadors in the fight against stigma, or b) unfairly advantaged in dealing with their personal mental distress, and therefore less deserving of sympathy and support than your “average” sufferer.

Tweets such as:

“Show me a millionaire footballer with depression and I’ll show him my last wage slip and then see who has more to worry about”

and:

“Depression is a disease and people get affected but surely seeing an extra £50k a week drop into your back pocket is a bit of a relief”

emphasise the fact that while being rich and famous cannot prevent mental distress, it can certainly cushion recovery by buying in services that reduce day-to-day worries and reduce stress levels. I would have undoubtedly coped better during acute bipolar episodes had I been able to afford childcare, a personal chef to feed us all, a cleaner, and a personal trainer to help me avoid gaining lots of weight due to misery and medication. Whilst I appreciated her candour, when Ruby Wax returned to the Priory for the 4 Goes Mad season, I was struck by the way she immediately felt relaxed and safe when she re-entered the ward environment. The mere smell of it, she said, was like sniffing a baby’s head. The contrast between the feelings expressed by people who have been voluntary or involuntary patients on NHS psychiatric wards could not have been greater. Mind’s independent inquiry into crisis care last year found that emergency mental services were very often too little, too late, and that inpatient services were some of the worst ward environments in the NHS and left many people frightened and traumatised. This is a world away from being able to check into a private care facility which feels safe and comforting, at a time of your choosing, before a crisis point is reached.

And yet, the disparity between celebrities’ experiences and those of ordinary service users is often glossed over. This is partly because large charities rely on entertainers, politicians, sportspeople and so on to act as champions and raise the profile of mental health. But it’s also part of a wider failure within the mental health community to address the issue of privilege.

For those not familiar with the concept, privilege is often used in feminist discussions as a useful and important way of recognising that although all women suffer under the patriarchy, not all women suffer equally. It would be nice to say, “hey, we’re all in it together!” but we know that simply isn’t true. For a start, women in countries where their human rights are enshrined are in a position of privilege compared to women in theocracies. As a white woman in a developed, open society, I need to remember that I am in a position of privilege over women of colour. Equally, as a woman with a disability, I would prefer that non-disabled women recognise and accept that I experience some difficulties that they do not.

My concern is that in taking the line that “rich or poor, we all suffer the same pain”, we are willfully ignoring that some people with mental health difficulties, no matter how much they distress they go through, are more fortunate (or in a position of greater privilege), than others. This can be hard for privileged individuals to accept. Because their illness makes them feel just awful, they are often unable to recognise that they have any degree of privilege at all and that there are others on the receiving end of not just emotional pain, but greater stigma and its effects.

For example:

–          The person is who is able to remain in employment enjoys a degree of privilege over those who cannot. Our culture routinely asks, “What do you do?”, using someone’s employment status as a means of determining their position in society, so those who cannot work are stigmatised. They also have less income and probably less wealth, and are more likely to have to go through the uncomfortable process of claiming benefits and being designated a “scrounger”. Furthermore, the more status a particular job has, the greater privilege it confers. So the footballer who manages to keep working through depression has privilege over the dinner lady who also just manages to hang on in there.

–          The person who is able to remain in work and struggle through the day, “faking it” to keep going until they get home, is also in a position of privilege. I’ve done faking it, It’s awful, is it painful, it’s a debilitating way to live, but the person who can do it still retains a level of choice. They can opt to carry on hiding it, or choose to disclose to a friend, a colleague, a manager. Someone who is floridly psychotic, acutely manic, or beset by panic attacks the minute they leave the house, does not have the luxury of choosing to appear well because their symptoms cannot be hidden. Once you have no control over your symptoms, you face the far greater stigma of seeming “crazy”, “a nutter”, someone a bit dangerous who no-one wants to sit next to on the bus.

–          Those who can be treated in primary care are privileged because there is far less stigma attached to GP services than to inpatient or outpatient psychiatric services. You can walk into a GP clinic and if a colleague sees, they won’t think twice. This is a privileged position compared to those who must walk through the front door of the CMHT or the psychiatric unit – there is only one inference to be drawn by anyone who sees you.

–          The person who has never been hospitalised faces less stigma than, and is therefore in a position of privilege over, someone who has. Those who have been “voluntary” patients are less stigmatised than those who have been sectioned. Sectioning brings legal stigma (e.g. you can’t be an MP or a company director, although we are very close, I hope, to getting this repealed), social stigma (especially if the MHA assessment was very noticeable to neighbours or police detained you in a public place), and concerns about privacy/confidentiality in terms of what the police may hold on record about you.

–          Mental ill-health is more common in groups facing poverty, and recent migrants such as refugees and asylum seekers are likely to experience both poverty and stress caused by leaving their support networks behind. Black and minority ethnic groups have greater difficulty in accessing NHS services they need, and BME people are over-represented in involuntary inpatient care. Service users who are from the majority culture and those who speak English fluently have a level of privilege over recent arrivals to the UK, those who do not speak English, and those from black or minority ethnic groups.

–          Heterosexual service users will experience a degree of privilege over those who are lesbian, gay or bisexual, as well as those who are transgendered. Studies show a higher than average rate of both mental distress and substance misuse among LGBT people.  Homophobic  and transphobic hate crime remains all too common an experience for members of the LGBT community, but those with mental health problems may face a double-whammy of stigma and discrimination.

–          Someone with a diagnosis of, say, anxiety or unipolar depression undoubtedly suffers greatly. But they are still in a position of privilege over someone with a less well-understood diagnosis such as a personality disorder, schizophrenia or schizo-affective disorder. People with more stigmatised diagnoses find it harder to get a job and have a greatly increased risk of being the targets or physical and/or verbal assault in their own local community.

I understand the reluctance to judge another’s individual, personal suffering. That’s impossible to do anyway. But if we work on a basic principle that “we all suffer the same, so we’re all in it together” we’re ignoring some pretty glaring differences between various places on the mental health spectrum. If we tell someone with poorly controlled schizophrenia or bipolar I that they are wrong to view their problems as worse than someone with a diagnosis of stress or mild depression, we are failing to acknowledge the reality of privilege. Yes, we all hurt from our illnesses. But some of us hurt and suffer additional effects of greater stigma and discrimination.

Of course I don’t want the likes of Stephen Fry, Ruby Wax or Stan Collymore to get back into the mental health closet. But it’s disingenuous to say that the suffering of celebrities is just like mine or yours. It also runs the risk that people will think, well, if Ruby can keep doing her stage shows, and Stephen can carry on with QI, and Stan’s out there as a “radio and TV broadcaster extraordinaire” (his words), how come you or I are still on the sofa, crying?

Perhaps we aren’t trying hard enough?

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