Institutional injustice: Implications for system transformation emerging from the mental health recovery narratives of people experiencing marginalisation

Abstract

Background Institutional injustice refers to structures that create disparities in resources, opportunities and representation. Marginalised people experience institutional injustice, inequalities and discrimination through intersecting personal characteristics and social circumstances. This study aimed to investigate sources of institutional injustice and their effects on marginalised people with experience of mental health problems. Methods Semi-structured interviews were conducted with 77 individuals from marginalised groups with experience of mental health problems, including psychosis, Black, Asian and minority ethnic (BAME) populations, complex needs and lived experience as a work requirement. These were analysed inductively enabling sensitising concepts to emerge. Findings Three processes of institutional injustice were identified: not being believed because of social status and personal backgrounds; not being heard where narratives did not align with dominant discourses, and not being acknowledged where aspects of identity were disregarded. Harmful outcomes included disengagement from formal institutions through fear and mistrust, tensions and reduced affiliation with informal institutions when trying to consolidate new ways of being, and damaging impacts on mental health and wellbeing through multiple oppression. Conclusions Institutional injustice perpetuates health inequalities and marginalised status. Master status, arising from dominant discourses and heuristic bias, overshadow the narratives and experiences of marginalised people. Cultural competency has the potential to improve heuristic availability through social understandings of narrative and experience, whilst coproduction and narrative development through approaches such as communities of practice might offer meaningful avenues for authentic expression.

Ethnic mental health inequalities and mental health policies in England 1999-2020

“…The findings highlight that Black and Afro-Caribbean people have continued to be disproportionately over-represented in mental health services and that mental health services are not meeting their needs (HM Government, 2018). BME people are likely to experience multiple forms of disadvantage relating to mental health, educational attainment and socio-economic status (Hui et al , 2021). Furthermore, BME people have been experiencing higher rates and frequencies of being sectioned, secluded and restrained and have been more likely to access mental health services via the criminal justice system (Wessely et al , 2018).…”

‘Maybe I Shouldn’t Talk’: The Role of Power in the Telling of Mental Health Recovery Stories

“…Interviews were conducted primarily to inform the development of conceptual frameworks describing recovery narratives and their impact, with the objectives of (1) accessing the recovery stories of a diverse population, and (2) exploring positive and negative impacts of accessing other people's stories. Findings on this data have been published elsewhere (Hui et al, 2021;Llewellyn-Beardsley et al, 2020;Slade et al, 2019). A secondary aim was to explore people's experiences of how they told their stories in various settings, and these experiences are reported here.…”

Psychiatry and/or recovery: a critical analysis

“…People who experience mental distress experience injustice when their identities are devalued through the acquisition of psychiatric diagnoses which in turn leads to stigmatization (Harper & Speed 2014). Institutional structures create injustice where there are disparities in resources, opportunities, and representation between majority and non-majority perspectives, for example, inequalities in access to treatment, experiences of health services, and treatment outcomes (Hui et al 2021). It occurs when treatment or services cause harm, even when the professed intentions underpinning the institution are benevolent.…”

“…It occurs when a person's treatment preferences are dismissed because the psychiatric diagnosis attributed to that person suggests an inability to think rationally or clearly (Kurs & Grinspoon 2018). In the face of this institutional injustice, it has been suggested that at the clinician level approaches are needed to avoid two related dangers: diagnostic overshadowing in which a person's experiences and physical symptoms are misattributed to mental illness and granting master status to one aspect of a person's identity by disregarding other aspects (Hui et al 2021). Given the chasm of differences between recovery principles and psychiatric discourse and the injustices embedded, is it possible to build a bridge between the two?…”