Impact case study database

Each year, around 1 in 4 people will suffer from a mental health problem. In the UK alone, this represents approximately 16,700,000 people, and it is on the rise: between 1993 and 2014, the number of people with common mental health problems rose by 20% ( https://webarchive.nationalarchives.gov.uk/20180328140249/http://digital.nhs.uk/catalogue/PUB21748). Meanwhile, BAME people are more likely to be diagnosed with a mental health disorder, are more likely to be detained under the Mental Health Act, and are less likely to receive treatment if in the criminal justice system.

Mad Pride began in the 1990s as a grass-roots campaign, aiming to resist stigma and to bring about change in societal views of mental health conditions. Mad Pride has been particularly controversial, given its rejection of the language of mental illness and its presentation of ‘madness’ as grounds for identity. Rashed’s research provided the evidence base to allow ideas from Mad Pride to productively inform clinical thinking and practice.

Mental Health Act Review

In 2018, Rashed was asked to provide expert evidence to the Independent Review of the Mental Health Act at the Department of Health. This was the first review of the Mental Health Act in 10 years, culminating in a final report (2). Key concerns driving the review included the rising levels of coercion within mental health services, and in finding the complex balance between respecting a person’s autonomy and the duty of a civilised State to protect the vulnerable (2). Rashed’s research examines this concern and can be read as an attempt to redress the balance towards patient autonomy (REF1, REF3, REF6). Rashed gave specific advice around cultural competence, cultural bias, and cultural and historic trauma (2).

The evidence that Rashed provided was incorporated into the report’s key findings as follows:

Cultural Competence

Rashed emphasised (2) the importance of not mistaking cultural beliefs and experiences for mental disorder and the need to seek cultural congruence, i.e. seeking harmony between the individual service user and their presumed cultural context. Moreover, Rashed pointed out that mental health disorder diagnoses happen when patients deviate from accepted epistemic, ethical or social norms. Thus, disorder diagnoses are more likely when clinicians and service users come from different cultural backgrounds, leading to a breakdown in cultural congruence.

The report consistently emphasises the need for clinicians and other service-providers to develop cultural competence (2), drawing on Rashed’s evidence when it states that a lack of cultural congruence can lead to misdiagnoses and that such misdiagnoses lead to an overrepresentation of ethnic minorities in detention. Furthermore, the report recognised that despite existing regulations, advocacy to meet the needs of diverse communities is not always available, again drawing on Rashed’s advice: ‘Where this is not happening,’ the report recommends, ‘commissioners should be held to account […] via the Organisational Competency Framework’ (2). Additionally, drawing on Rashed’s evidence, the report notes an ‘insufficient’ focus on training for NHS staff on cultural competency, noting that a lack of competency poses a significant barrier to appropriate treatment for patients with protected characteristics (i.e. those covered by the Equality Act 2010). It recommends, ‘as a minimum’ that government ensure that regulations and standards governing key decision-making professions ‘are relevant and fit for purpose’. This, again, reflects Rashed’s evidence to the panel (2).

Cultural Awareness

Recommendations that drew directly on Rashed’s evidence in relation to cultural awareness include:

- Ensuring the provision of culturally-appropriate advocacy services (including Independent Mental Health Advocates) for people of ethnic minority backgrounds

- Amend the Code of Practice to reinforce the […] considerations of cultural needs and build on [patients’] own knowledge and experience of their mental illness

In addition, the report dedicates specific segments to “recognising individual and cultural needs” and “culturally-appropriate advocacy”. It notes that “the provision of culturally-appropriate advocacy is key to reducing additional stresses and anxieties that could exacerbate a patient’s mental condition, as well as to support speedier recovery”. Culturally-appropriate advocacy will “help reduce the likelihood of people experiencing mental health services as abusive and that disenfranchised patients have their views heard, recorded and considered, and that dignity is upheld”.

The white paper to reform the Mental Health Act has been delayed, initially due to the general election and then the Covid crisis. In the meantime, the Care Quality Commission have published their Monitoring the Mental Health Act in 2019/20 report (3), which highlights the need for greater access to advocacy services, one of the key recommendations put forward by the Independent Review of the Mental Health Act (2).

Legal practice

39 Essex Chambers is “widely regarded as having the biggest and best health and welfare team in London or anywhere else”. Their monthly Mental Health Capacity Report is a training resource that supports other Chambers to interpret and understand mental health issues. Their April 2019 Report cites [REF1] as raising questions concerning the “validity of psychiatry as a response to ‘madness and distress’”, in the context of the UN Convention on the Rights of Persons with Disability (4). Using high profile cases, such as Rachel Johnston (a severely disabled woman who died in 2019 after her teeth were removed without her consent or her mother’s knowledge (5), they highlight the ongoing debate over the capacity of people with mental health disabilities to determine their own treatment. Rashed has argued for more autonomy for people with mental health problems, both in terms of decisions concerning their care as well as the broader understanding and meaning of these problems. The following month, the Chambers cited Rashed again [REF3], this time in the ‘Research Corner’ section of their newsletter, which highlights recent research articles likely to be of interest to practitioners (6). This edition of the Report highlights a case heard in which a woman on the autistic spectrum and with a severe learning disability was given a hysterectomy to alleviate the profound distress that her menstrual cycle caused her. This was a case about autonomy, capacity, and the best interests of individuals, and Rashed’s article on mental health and the social model of disability [REF3] was recommended reading in this context.

Public Health Guidance

Rashed’s work has influenced internal government guidance on mental health. Public Health England’s (PHE) Knowledge and Library Services provides “knowledge, library and evidence services to PHE” in order to “protect and improve the nation’s health and wellbeing, and reduce inequalities, by providing and mobilising the best available evidence for public health”. As part of their remit the service regularly publishes a Mental Health Current Awareness Update ( MHCAU), providing PHE with “the latest, best evidence about mental health, to help (PHE staff) make informed decisions” that affect healthcare provision at the national level, and provides a curated, up to date reading list of the best, most valuable research on mental health. The June 2020 MHCAU (7) cites [REF1] as among the most important recent studies.

Clinical Practice

In 2019, Rashed conducted workshops at the Royal College of Psychiatry. The workshops brought together psychiatrists and other mental health professionals, service-users, and third-sector workers. That is a significant achievement in itself given the historical resistance that these groups often have to such interventions, and testament to Rashed’s standing among clinicians, professionals and service users. The workshops introduced practitioners and other stakeholders to key concepts conducive to working with Mad Pride in clinical practice. They were targeted specifically at senior practitioners with specialist expertise, increasing the reach across their institutions and across the sector. The workshops’ approach drew on a mixture of focus groups and teaching/training methods, maximising the impacts by developing concepts and drawing out participants’ understandings and insights.

Many senior practitioners reported a range of benefits and changed practice as a result of the workshops:

- “I will develop this distinction with my trainees as part of reflective practice” (NHS consultant clinical psychologist).

- “This […] has helped me think in new ways about the clinical encounter and mental health” (senior academic in practice-based medical humanities and advisor to the Royal College of Psychiatry).

- The workshop “made me aware of the multi-faceted nature of reconciliation and forgiveness […] my research could look at this theme with regards to patient groups” (consultant psychiatrist at a community mental health team).

- “the discussion of concepts [was] useful in clarifying arguments in my work” (consultant psychiatrist working in policy and public health) (8).

Rashed’s research has directly and fundamentally affected private practice in the sector, too. The Clinical Director and chartered psychologist of independent psychological healthcare practice Psychology Sussex states that Rashed’s research has been “invaluable in the field of mental health, especially with regard to broadening the perspective on the experience of ‘madness’, and implications for mental health practice” (9). Rashed’s critique on the categorisation of individuals and informative embrace of lived experience has been fully incorporated into the practice’s in-house CPD training, positively influencing therapeutic interventions with clients (9). This training has been delivered to the 40-strong team, who each conduct between 10 and 20 therapy sessions per week, equating to approximately 19,200 sessions per year conducted with an average of 500 service users. The Clinical Director subsequently invited Rashed to speak at Soteria Brighton, the local branch of a global network of practitioners. Around 100 practitioners and lived-experience users will attend the future session and it will be uploaded on to the global Soteria Network, accessible to anyone affiliated with Soteria. The Brighton branch alone reaches around 500 people (practitioners and service users) (9).

Rashed’s work has further influenced the practice of clinical psychologists globally. A clinical psychologist and researcher from Frankfurt, Germany praised [REF1] as “the first substantial book in the field” and “very inspiring […] it’s now possible to discuss the implications of the concept [of recognition] and its potentials and limits [in mental health] based on your work”.

Charities and other public organisations

Pink Sky Thinking, a Mad Studies reading group of lived experience practitioners and consultants, service-users, and activists ( https://www.pinkskythinking.com/post/mad-studies-david-tackles-madness-the-demand-for-recognition) used [REF1] to encourage “people to use different language, and to participate [in activism] differently” (8, 10). A review by a lived experience researcher and mental health activist has also noted that [REF1] “amplifies the value of Mad Pride efforts to bring about societal transformation, and may offer us some theoretical anchors […] to bolster our activities” (10). The book is also cited as a resource by mental health activists’ website, Radical Abolitionist (10).

In August 2018, the non-profit Mad in America invited Rashed to deliver a webinar on his research to mental health practitioners and service-users (10). The forty-five US-based participants included psychiatrists, psychologists, therapists, activists, and service-users, reporting that the webinar created “new learning” and inspired users to understand Mad narratives as “part of clinical encounters”.