Prevalence and experience of harassment of people with mental health problems living in the community

Background The levels and experiences of harassment of peoplewith mental health problems in the community compared withthose of the general population have not been explored.

Aims To measure the levels and experience of harassment experienced by people with mental health problems in the community in Scotlandand compare them with the general population.

Method Experiences of harassment were collected by interviewing165 individuals with mental health problems and a control groupof 165 people from the general population.

Results Harassment in the community was found to be twice ascommon for individuals with mental health problems (41%) thanfor those in the general population (15%). The harassment commonlyinvolved verbal abuse referring to the individual's mentalhealth problems and was committed primarily by teenagers andneighbours.

Conclusions Harassment has a significantly higher prevalenceamong individuals with mental health problems living in thecommunity and is believed to have a detrimental effect on mentalhealth.

INTRODUCTION

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INTRODUCTION

Stigma and discrimination have long been problems for peoplewith mental health problems living in the community, and arecurrently the focus of campaigns by, among others, the RoyalCollege of Psychiatrists (2001) and the Department of Health(2001). This research was prompted by concerns from mentalhealth organisations hearing anecdotal accounts of individualsexperiencing harassment in their communities. No previous researchexplored the prevalence of such harassment, particularly in comparison with the general population and across differentcommunities. Only one study, carried out for MIND, had examinedharassment previously, finding that 50% of its respondentshad experienced harassment in the workplace and community (Read & Baker, 1996).The study was limited, however, by itsuse of a self-selecting sample. Kelly & McKenna (1997)found that 60% of their sample (in a quality-of-life study)experienced harassment, the majority living in local authority‘difficult to let’ areas.

METHOD

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METHOD

Definition of harassment
There is no single definition of harassment: it can take a varietyof forms, both verbal and physical, and have a variety of motives.It can be conducted by one person or a group of people, againstone person or several. The impact of a specific behaviour willbe different depending on the individual who experiences it;additionally, perpetrators of harassment may not see theirbehaviour as causing distress to others.

For the purposes of this research, harassment was defined as:

a person carrying out an action that may reasonably result inanother feeling harassed;
the act need not necessarily berepeated;
the perpetrator need not necessarily have actedwith intent.

For the purposes of the study, community-based harassment embraced harassment both within and outside of the home, but excludedworkplace harassment, childhood abuse and domestic abuse.

The Multi Centre Research Ethics Committee for Scotland andthe appropriate local research ethics committees granted ethicalapproval for the study.

Sample
Study areas
The four types of area that were sampled were those typicalin Scotland:

cities (Aberdeen, Glasgow and Dundee);
towns (East Kilbride,Hamilton, Falkirk and Cumbernauld);
peripheral housing estates(Drumchapel and Castlemilk, bothperipheral to Glasgow);
scatteredrural settlements (Dumfries and Galloway).

Each site was served by one or more community mental healthteams through which the sample was accessed. It was not theintention to make systematic comparisons between the differentlocalities.

A total of 165 individuals with mental health problems and 165individuals in the general population were interviewed. Eachsample comprised interviews with 40 people from each of cities,towns and rural settlements and 45 from peripheral housingestates.

Inclusion criteria
The individuals with mental health problems were experiencingsevere and enduring mental health problems as defined by theScottish Framework for Mental Health Services (Scottish Executive, 1997).The assumption was that the mental health problems ofthese individuals would have had more impact on their livesthan those of individuals who had experienced a single episodeor problems of a more transient nature. The age range was between25 and 65 years.

Exclusion criteria
People with dementia were excluded as being a distinct groupwith particular needs. Homeless people also were excluded fromthe sample. It was considered that the nature of this population,including high incidences of mental health problems, wouldlead to difficulties in providing a matched sample. In thegeneral population, those who had been in contact with mental health services within the past 10 years were excluded.

Research instruments
A face-to-face interview was chosen to provide a safe environmentwithin which the complex issues of harassment could be explored.The interview was structured in format but allowed less structuredresponses when taking descriptions of any incidents of harassment.The interview schedule was developed after a series of focusgroups involving people using mental health services in boththe voluntary and statutory sectors. The same interview was administered to both sample groups.

The interview provided socio-demographic information. Intervieweeswere asked if they felt that they had experienced harassmentand, if so, they were asked to describe their experiences.The interviewers recorded the experiences, using prompts toensure that information was gathered about what the harassmentconsisted of, where it had taken place, who was committing it, why it was felt to be occurring and the impact it had on theinterviewee.

Procedure
Each community mental health team was approached and asked toaccess a sample of its users. Service users meeting the inclusioncriteria were approached by their community psychiatric nurseand asked if they would be prepared to be interviewed. If consentwas given, they received an information sheet and their detailswere passed to the researcher. The researcher then contactedthem to arrange the interview. All participants were interviewedin their own homes or at their resource centre. The generalpopulation was assessed by interviewers calling at their homesand matching them on gender, age and type of housing.

The data were collected between June 2000 and March 2001. Ateam of eight specifically trained interviewers carried outthe interviews.

Analysis
The quantitative data were analysed using MINITAB, Version 12for Windows. Comparisons between subgroups were made usingthe ${chi}$ ² test. The qualitative data were analysed using QSR NUD^*IST.

RESULTS

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RESULTS

A total of 330 people were interviewed: 165 people with mentalhealth problems and 165 people in the general population.

Socio-demographic characteristics
Table 1 reports the socio-demographic characteristics of thetwo samples, including gender, age and employment status. Ifthey were unemployed, they were asked how often they went outof the home. The table gives information about the type of property the participants lived in, whether they lived alone and thelength of time they had lived in both their property and thearea.

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Table 1 Socio-demographic characteristics of participants (n, %)

There was a significant difference between the numbers of peoplein employment in the two groups: 53% (n=88/165) of the general population were employed or were students compared with 5%(n=9/165) of people with mental health problems. All thosewith mental health problems (n=6) and 35% (n=29/84) of thosein the general population who were employed worked part-time.Those who were unemployed (n=233/330) were asked how oftenthey went out of their homes. Eighty per cent or more of bothsamples said that they went out either on a daily basis orseveral times each week. Forty-five per cent (n=45) of the peoplewith mental health problems lived alone, which was 30% morethan in the general population (n=25).

The ownership of property differed between the groups: 21% (n=93) more people with mental health problems lived in local-authority-owned accommodation than in the general population (n=60). Over 70%of both samples (sample with mental health problems, n=121/165;general population sample, n=117/165) had lived in their areafor over 20 years.

Levels of harassment
Table 2 shows the overall reporting of harassment and wherethe harassment occurred. Sixty per cent (99/165) of peoplewith mental health problems and 44% (73/165) of the general population reported experiencing some form of harassment ( ${chi}$ ²=8.21,P=0.004). Figures for incidences of harassment in the workplaceand bullying while at school are detailed in Table 2 but arenot included in the full analysis. There was a significantdifference in the overall levels of harassment between theindividuals with mental health problems and the general population.There was a significant difference in the location of the harassment,with 41% (67/165) of people with mental health problems experiencingharassment in the community compared with 15% (24/165) of the general population ( ${chi}$ ²=20.42, P<0.001). People from the generalpopulation were more likely to have experienced harassment inthe work-place, reflecting the higher number of this samplein employment ( ${chi}$ ²=13.33, P<0.001).

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Table 2 Overall reporting of harassment by setting (n, %)

The results reported below refer only to the harassment experiencedin a community setting.

Socio-demographic characteristics and harassment
There were three socio-demographic variables showing significance.As can be seen in Table 3, age showed a significant influenceon whether a person with mental health problems had experiencedharassment, although this was not the case in the general population( ${chi}$ ²=8.77, P=0.033). When the two samples were combined an influencewas shown but, because it was a weak level, it was not thoughtto be reliable ( ${chi}$ ²=8.40, P=0.038). A significant associationbetween people living in local authority accommodation andthe prevalence of harassment was evidenced within the generalpopulation sample and when both samples were tested.

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Table 3 Significant impact on harassment by socio-demographic indicators

The type of area in which people lived did not influence whetherthey were likely to experience harassment or not. The prevalenceof harassment between the two samples differed to the sameextent across all areas (between 27% and 30%), except in thecities, where it was 17%. People living on their own were notsignificantly more likely to have experienced harassment, althoughthere was a higher prevalence across both samples. A lower(but not significant) number had experienced harassment whileliving in supported accommodation compared with those peopleliving in mainstream accommodation.

Features of harassment
Table 4 shows that in both samples verbal abuse was the mostcommon form of harassment. There was one feature specific tothe people with mental health problems that over half of thesample described: having those problems exposed. This happenedmost commonly alongside verbal abuse. People frequently spokeof being called derogatory names:

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Table 4 Features of the harassment (n, %)

‘...they waited for me and followed me again, they werecalling me names such as "loony" and saying "you should belocked up"’. (Woman, 25-34 years, Dundee)

Unwanted interference frequently was reported, taking variousforms including false accusations to the authorities or nuisancetelephone calls.

‘I started getting telephone calls about two and a halfyears ago. Groups of kids and young people were making callsto my house. They had found out I was on my own and I was fairgame.’ (Man, 45-54 years, Aberdeen)

The general population also described similar incidents:

‘On Friday night, two days ago, our window was brokenby a gang of teenagers who are targeting us.’ (Man [generalpopulation] 35-44 years, Cumbernauld)

Other features of harassment that interviewees described includedbeing physically threatened and, on occasion, actually assaulted.

Who was committing the harassment
Teenagers and neighbours were the two groups most frequentlymentioned as committing the harassment across both samplesand all types of area. The teenagers committing the harassmentwere often in groups of two or more:

‘It was mainly young people about the streets aged about14 or 15.’ (Man, 44-55 years, Drumchapel)

The harassment from teenagers predominantly consisted of verbalabuse; they were largely thought to commit harassment as aresult of influence from either their parents or peers. Teenagers'ignorance of mental health problems also was given as a reasonfor their behaviour.

The general population also described harassment from teenagers:

‘they hang around in my close [communal stair-case] drinkingand using abusive language at all hours and throwing stonesat my windows.’ (Woman [general population], 25-34 years,Castlemilk)

Neighbours also primarily committed verbal abuse:

‘Two neighbours, one I had helped in the past, laughedat me and made "mental" signs at me.’ (Woman, 55-65 years,Drumchapel)

The finding that 21% of the interviewees with mental healthproblems had experienced harassment coming from within theirfamilies was unexpected; nobody from the general populationspoke of harassment coming from within their family:

‘My brother-in-law used to harass me for my sleeping tablets.’ (Man, 35-44 years, East Kilbride)

This harassment was not as a result of ‘overanxious’carers reminding people to take medication: it was of a specificallymalicious nature. People described being taken advantage offor their welfare benefits or medication, the relative knowingthat they felt unable to stand up for themselves. They alsofelt that their mental health problems were often referredto, with family members calling them names and making derogatory references to their mental health:

‘It sounds stupid but I had ECT [electroconvulsive therapy]treatment for my depression and members of my family, especiallymy sister, thinks it's funny. She calls me "sparky". I findit very hurtful and I've tried to talk to them but she keepson about it.’ (Man, 55-65 years, Dundee)

Why people felt that they were experiencing harassment
There were substantial differences between the samples in thereasons why people felt that they were experiencing harassment.When the people with mental health problems knew the personcommitting the harassment, the majority felt that it was happeningbecause they were known to have mental health problems:

‘They do it because they don't understand mental health problems.’ (Woman, 45-54 years, Castlemilk)

The majority of people in the general population saw the motivefor the harassment as fulfilling a need of the harasser, suchas to try to get money or, in the case of teenagers, lookingfor something to do:

‘Children do it for sheer devilment, they want to annoy somebody.’ (Woman [general population], 55-65 years,Drumchapel)

When the motive for the harassment was felt to be mental healthproblems, vulnerability or the person being different in someway, the most frequent feature of the harassment was verbalabuse, often in conjunction with exposing the mental healthproblems.

Reporting the harassment
For the purposes of this study the reporting of harassment wasboth formal, for example to the police, and informal, for exampleto medical or support staff. People with mental health problemswere more reluctant to report harassment than were the generalpopulation. Nearly three-quarters of the general population(n=17/24, 71%) went to the police, compared with just underhalf of the people with mental health problems (n=29, 43%).

There are several potential reasons why people with mental healthproblems may be reluctant to involve the police. There maybe a fear that they will not be taken seriously and that thecomplaints they wish to make will be seen as a manifestationof their mental health problem. Because the police often can become involved with people with mental health problems underthe Mental Health Act, individuals also may be wary of havingvoluntary contact, especially if they have had a negative experiencein the past:

‘The police have targeted me - I think they don't realisethat I am ill. Last time I was admitted they had to come forme... I don't like the police, I try to tell them when I amhigh.’ (Man, 55-65 years, Falkirk)

The majority of people reported the harassment to more thanone agency and nearly half of the people with mental healthproblems also told medical or support staff about their problems:

‘I reported it to my CPN [community psychiatric nurse]butthere is nothing my CPN can do about it’. (Woman,55-65 years, Drumchapel)

The majority of both groups found that reporting the harassmentmade no difference. This may make people reluctant to reportfurther incidents to the police, which will have an impacton the monitoring of incidents that allows the police to targettheir services most effectively.

Although the general population reported the harassment morefrequently, some had fears of repercussions if they involvedthe police:

‘I was going to go to the police but I was worried itwould cause more hassle.’ (Woman [general population],35-44 years, Drumchapel)

Strategies to try to stop harassment
Strategies included any action at all taken by the person otherthan reporting it. Over one-third (n=31, 46%) of the peoplewith mental health problems took no action to attempt to stopthe harassment. If they did take action it was the act of movinghouse; in fact, more people with mental health problems hadmoved house (n=20, 30%) than had tried to reason with the harasser(n=11, 16%):

‘I applied for a move to the housing officer and got movedto where I live now where I am much happier and don't get anytrouble.’ (Man, 25-34 years, Glasgow)

Continuing harassment
Nearly half (n=30/67, 45%) of the people with mental health problems who had experienced harassment were still experiencingit at the time of interview. In the general population, theharassment was ongoing for a similar percentage of those whohad experienced it (n=10/24, 42%).

Of the people with mental health problems experiencing continuing harassment, one-third (n=10/30, 33%) had reported it to thepolice and half additionally had reported it to medical professionalsor support staff (n=15/30, 50%). Not surprisingly, the majorityof these people felt that reporting had not made any difference.One-third of people had not reported the harassment at all.

Impact of harassment
Almost all the interviewees with mental health problems referredto the adverse effect that the harassment had had on theirmental health. This was particularly the case when they feltthat they were being harassed as a result of their mental health:

‘I ended up in hospital virtually every month and my conditionbecame worse.’ (Woman, 35-44 years, Dumfries and Galloway)

Half of the general population sample in this study who experienced harassment spoke of a detrimental effect on their mental health.

‘I became very stressed. My hair was falling out and Iwas very depressed.’ (Woman [general population], 25-34years, Aberdeen)

Overall, across the two samples, three-quarters said that theirmental health had been affected.

Anger and annoyance was described most frequently by the generalpopulation (n=21/24, 88%) and second most frequently describedby people with mental health problems:

‘I was very angry and wanted to put their heads throughthe wall, but that's no answer.’ (Man, 55-65 years, Drumchapel)

One difference between the responses of the two samples to harassmentwas the level of fear in certain circumstances. If the harasserwas not known to the individuals, a higher percentage of thegeneral population talked of being annoyed than of the peoplewith mental health problems, who more frequently describedfear. Fear also was a common response when individuals feltthat they were being harassed because of their mental healthproblems. Fear had resulted in people feeling the need to takeactions to defend themselves from the perceived or actual threat:

‘I actually sat in front of the TV one night with a rollingpin and a knife because I was worried they would get in andtry and hurt me.’ (Woman, 35-44 years, Drumchapel)

A woman interviewee in Drumchapel described a situation whereher neighbours were kicking her door to intimidate her. Shehad contacted the police and, while waiting for them to arrive,had picked up a knife. She describes how, understandably,

‘The police misread the situation; even after I had putdown the knife the attitude from the police was that I wasthe culprit, not my neighbour.’ (Woman, 45-54 years,Drumchapel)

Preventing harassment
All interviewees, regardless of whether they had experiencedharassment or not, were asked what they felt would help tostop or prevent harassment. The responses were very similaracross both groups. The most commonly cited response was ‘education’.This was either education of the general public, with the aimof increasing knowledge and awareness of mental health problems,or education about the impact that antisocial behaviour canhave on those who are its victims:

‘Children should be educated so that they learn that peoplecannot help being different. The parents need to be educatedas well so that they can stop the children behaving in thisway.' (Woman, 45-54 years, Drumchapel)

Intrinsically linked to education, and the second most commonresponse, was a call for a positive change in public attitudestowards people with mental health problems.

DISCUSSION

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DISCUSSION

Overall prevalence of harassment
This is the first study to compare the harassment of peoplewith mental health problems with that of the general population.In total, people with mental health problems were more likelyto experience harassment than the general population. Thisstudy is thus able to support the findings of Read & Baker(1996), who described half of their respondents experiencingharassment; although the present study shows a lower overallprevalence, it achieved its sample in a more representativemanner. Because there are a greater number of people in thegeneral population sample who are in employment, they have more opportunity to experience workplace harassment. It seems thathaving mental health problems leaves people more vulnerableto experiencing harassment in their communities.

Only three people in this study came from ethnic minorities,therefore harassment of this group cannot be discussed. Itis difficult to obtain figures for the likelihood of peopleexperiencing harassment for other reasons such as race or gender,largely owing to the low level of reporting of ‘low-levelharassment’ typified by verbal abuse. However, it is generallyaccepted that people from minority ethnic communities experience widespread racially motivated harassment (Social Exclusion Unit, 2002).Our study shows that having mental health problemscan be treated also as a predictor of whether a person is likelyto experience harassment.

The requirement by the Multi Centre Research Ethics Committeethat community psychiatric nurses should approach patientsmay have led to a selective sample, possibly with a bias towardswomen and to people they felt would be more amenable to takingpart or more likely to have experienced harassment. Likewise,because people from ethnic minorities are already known touse community mental health services less, community psychiatricnurses might have approached fewer of these people (Sainsbury Centre for Mental Health, 2002).

Individual differences
Similar amounts of harassment were reported by both gendersin both samples. It might have been hypothesised that womenexperience more harassment than men, because of sexual harassment.This may be the case in the workplace but this study did notfind an equivalent within the community. It is not known whyage showed an influence on whether people had experienced harassment in the community. How frequently people left the house wassignificant to whether the general population sample and thetwo samples combined experienced harassment. It is felt thatit did not prove to be significant for the sample of peoplewith mental health problems because they experience harassmentfrom within their own families without necessarily leavingtheir homes.

Property and location
Although there are many studies exploring public attitudes towardspeople with mental health problems in different types of neighbourhood (Brockington et al, 1993; Huxley, 1993; Wolff et al, 1996), they do not explore the actual behaviour of the community.The findings of this study show that it made little differencewhere people lived: people with mental health problems weremore likely to have experienced harassment than the generalpopulation, wherever they lived. However, because the combined samples living in local authority accommodation were significantlymore likely to experience harassment, this seems to indicatethat there was a higher prevalence in lower socio-economicclass areas (assuming property tenure as a proxy for socio-economicstatus), supporting the findings of Kelly & McKenna (1997).

Living in supported accommodation has the potential either todraw attention to a person's mental health problems or to offersome protection through staff presence. People living in thisaccommodation were by no means entirely protected from harassmentbut it was slightly less prevalent than for people living inunsupported accommodation.

Features of the harassment
These findings show that for the 41% of people with mental healthproblems who had experienced harassment it had had a seriousimpact on their lives. As the majority of people with mentalhealth problems are supported within the community, the experiencethere has the potential to profoundly affect their prognosisand overall quality of life. Mental health professionals needto be aware of these effects and be able to offer support andadvice to their patients with confidence. Practitioners alsomust be proactive in raising the subject of patients' communityexperiences because patients may not recognise that this isa problem for which support can be provided.

There is an inherent difficulty in trying to identify why peoplewere being harassed when only having access to the opinionof the victim. Participants were not asked why they felt theywere harassed as a result of their mental health problems becausethis was felt to be too sensitive an area. This informationtherefore was acquired only if the participant volunteered it.It could be argued that the people with mental health problemswere assuming that they were being harassed as a result oftheir mental health problems when this was not actually thecase, or that they expected to be harassed because they recognisedthe stigma of their condition. Because almost half of the harassmentthat interviewees experienced, particularly verbal abuse, explicitlyreferred to their mental health problems, this counters theabove suggestion.

The findings in this study are similar to those of Kelly &McKenna (1997), with reports of children and teenagers committingwhat they termed ‘low-level victimisation’, includingverbal abuse and attacks on property. They describe a similarscenario where people with mental health problems felt the needto arm themselves, potentially putting themselves at risk from prosecution.

There is little previous evidence looking at the impact thatharassment can have on people with mental health problems.This study has shown, however, that harassment can affect themental health of people without previous mental health problems.

The numbers of people moving house in this study had similaritiesto Read & Baker's (1996) study, which found that 26% ofpeople with mental health problems experiencing harassmentmoved house; this study showed a value of 30% (20/67). Becausethe results found no significant variations in harassment acrossdifferent areas, this suggests that moving house is no guaranteethat the harassment will not start again.

Anti-stigma campaigns
Because so much of this harassment is thought to occur as aresult of negative public attitudes towards mental illness,continuing anti-stigma work must be given priority, such asthat of the Royal College of Psychiatrists (2001) and the Departmentof Health (2001), as well as that carried out by devolvedgovernment and local initiatives.

With so much of the harassment committed by young people, thisgroup in particular should be targeted in the most immediatecampaigns in order to counter these negative attitudes.

Clinical Implications and Limitations

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Clinical Implications and...

CLINICAL IMPLICATIONS

Professionals should be aware that harassment is a problem fora significant number of people with mental health problems,regardless of the type of area in which they live. The communityexperience of patients, therefore, must be assessed regularlyduring consultation.
The importance of anti-stigma initiativesat both a local and national level must be recognised.
Professionalsneed to have knowledge of where to refer patients experiencingsuch difficulties for specific assistance andsupport withinthe context of multi-disciplinary support andmulti-agencyworking.

LIMITATIONS

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LIMITATIONS

It is impossible to assess objectively why a person becomesthe target for harassment without having access to the perpetrator.
By its very nature, the experience of harassment is subjectiveand people assume a causal relationship between harassmentand deterioration in their mental health when other factorsmay have played a part.
There was possible selection biasand lack of ethnic minority representation.

ACKNOWLEDGMENTS

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ACKNOWLEDGMENTS

We would like to acknowledge Harper Gilmour for assistance withstatistical analysis.

REFERENCES

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