Structural Violence, Social Justice, and Mental Illness

Combating social exclusion is central to achieving social justice for people with enduring mental illness and their families.

Source: Artem Podrez/Pexels

"Structural violence" is the term given to forces such as poverty, racism, inequality, and discrimination, which necessarily have an influence on people’s health, including their mental health. These factors not only affect patterns of susceptibility and exposure but can also limit the effectiveness of health care systems and reduce access to services, especially among the poor.

Both homelessness and imprisonment are substantially more common among people with mental illness than the general population. This situation is, for the most part, not attributable to mental illness itself, but rather to the ways in which mental illness is patterned, interpreted, and treated by societies. This results in the denial of rights, denial of opportunity, and broad-based social exclusion of people with mental illness and their families. Let’s consider homelessness first.

People with enduring mental illness are at increased risk of homelessness in virtually every country around the world. Approximately 11 percent of homeless people have schizophrenia, compared to less than 1 percent of the general population. Treatment can be very challenging as homeless people with schizophrenia often find it difficult to engage with treatment and are especially vulnerable, owing to their homelessness. Moreover, homelessness is more common among people with earlier onset of schizophrenia, more severe symptoms, and co-existing substance misuse—all of which make engagement more challenging, although by no means impossible.

The reasons for homelessness are many and varied. Owing to the illness itself, some people might experience difficulty sustaining a tenancy or remaining in a family home, especially if there is also a problem with substance misuse. In addition, there is clear evidence that people with severe mental illness encounter problems accessing community care services following discharge from the hospital and additional difficulties adapting to housing following prolonged periods of homelessness. All of these issues substantially complicate the process of reintegration into society. Much of this difficulty is attributable to relatively poor links between mental health and social services in many countries.

People with mental illness are also grossly overrepresented in prison populations, which have much higher rates of depression, psychosis, and substance misuse than the general population. There are a number of possible explanations for this. In the first instance, people with major mental illness, such as schizophrenia, may be slightly more likely to engage in certain offenses than those without mental illness, even though, at a societal level, the proportion of violence attributable to mental illness is very small. Most people with mental illness are far more likely to be victims rather than perpetrators of crime. The vast majority are not at all violent, and among those who are, risk factors for violence are the same as in the general population: young age, male gender, being single, poverty, and substance misuse.

People with mental illness are, however, more likely than those without mental illness to be arrested in similar circumstances, and remand is more likely even when lesser offending is associated with mental illness. This results in the disproportionate imprisonment of people with mental illness, often because there appears to be no other more appropriate option available to police or judges following an arrest.

This contributes to a phenomenon known as "Penrose’s Law," named after Professor Lionel Penrose (1898-1972) who studied data from 14 European countries and concluded that the number of people in "mental institutions" was inversely correlated with the number in prisons: i.e., when the number of people in "mental institutions" fell, the number in prisons rose. This does not mean that large psychiatric hospitals are the answer, but rather that community mental health services need to be improved to provide better, earlier treatments and prevent people from ending up in prison unnecessarily.

Remedying the stigma, social injustice, and "structural violence" experienced by people with mental illness and their families is a challenging, important, and increasingly urgent task. This is a task for everyone: people with mental illness, families, carers, mental health professionals, politicians, policymakers, and the public in general.

Many of the potential solutions lie in the realm of political action. In addition to exerting pressure on governments for improvements in services, there is a central role for voting as a means to generate change through the political process. For this mechanism to be effective, however, it is important to register to vote in the first place. Voter registration programs aimed at people with mental illness, especially those in residential settings, are a good place to start.

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Ultimately, active political participation is the most potentially transformative path to better protecting and promoting the rights of people with mental illness. In the words of Rudolf Virchow (1821-1902), the German pathologist, anthropologist, and politician: "Medicine is a social science, and politics nothing but medicine on a large scale."