Today we have a blog post from IMH Director Professor Nick Manning, with, as an introduction, some questions to think about and a link to a lecture by Professor Nikolas Rose. Together, this post and lecture provide a ‘sociological’ view of mental health, and hopefully will provide some food for thought over the Christmas break.
Visiting this link will take you to a ‘mediasite’ presentation by Professor Nikolas Rose, entitled ‘What is mental health today?’. Please note that viewing this video may require additional plugins on your web browser. If you are prompted to install Microsoft Silverlight, it is safe to do so, and you will need to restart your browser for the changes to take effect. Other lectures by Professor Rose can be found here.
Some questions to think about when watching the video, and while reading Professor Manning’s post, which follows:
1. Is there an epidemic of mental disorder?
2. Does the path to understanding mental disorder lie through the brain?
3. What is the role of diagnosis and diagnostic manuals?
4. Should we seek early diagnosis of those at risk of future mental pathology?
5. What is the place of patients, users, survivors, consumers in the mental health system?
Professor Manning’s Post
Over the last 20 years a number of critical issues have challenged the mental health field in two areas.
First, the evidence for and effectiveness of treatment has been criticised for:
- the integrity and relevance of research (pharma company trials, for example on the effectiveness of SSRIs and atypical anti-psychotics);
- promissory claims by genetics and biological psychiatry research, which have not revealed hoped-for breakthroughs;
- the extent of the evidence base (RCTs, NICE, complex interventions, which have not offered strong support for singular interventions);
- the effectiveness of new technologies (CBT, DSPD are being challenged, and the latter investment has been wound up after 10 years and £0.25 billion)
Second, there has been criticism of the care and treatment practice, such as
- the quality of care (murders by Christopher Clunis, Michael Stone, Richard King; care home scandals such as Winterbourne View; public enquiries such as the death of David Rocky Bennett);
- the development of European and UK mental health legislation (risk prediction is weak and hence compulsory treatment and legal advice are contested).
The pattern here is for research based on an aetiology and pathology of mental illness in terms of biological processes and structures to have made limited progress. A recent UK Medical Research Council review of mental health research in the UK concludes that “the research questions in this field have been relatively intractable” (MRC, 2010). Genetic markers have been elusive, neuroscience has yet to show clear directions for diagnosis and treatment, psychological treatments and effective drugs have been disappointing. Yet the biomedical model has retained its dominance, despite the limitations of pharmaceutical, genetic, neuroscientific and psychologically based interventions.
By contrast there is a body of work from social science in relation to epidemiology and therapy, which demonstrates clearly the working of social processes in the distribution and care of mental illness. For example there has been growing evidence for the last 50 years that mental illness rates are related to the social inequalities of race, gender, age, migration, and unemployment (Pilgrim and Rogers, 2009). Part of this pattern is a selection effect caused by prejudice and stigma, for which the social theory of labelling, developed in the 1960s, provides evidence and explanation (see Scheff, 1999 for a summary). But part of this is direct causation mediated through stress (see Wilkinson and Pickett 2010 for a summary). In terms of therapy there is social science evidence about the damage poor treatment environments can do (Goffman, 1991, et seq), and the consequences of social isolation under community care. There is also evidence about the way in which those treatment environments can be positive and therapeutic (Lees, 2004), and about the potential for building better supportive personal and social networks (Spencer and Pahl, 2006).
At the same time there has been a growing burden of mental distress. Bloom, et al (2011, p.26) estimate that mental disorder is the leading global cause of all disability-adjusted life-years. Suicide is second only to traffic accidents as the cause of death among those aged 15–35 years (WHO, 2005). 75% of prisoners in the UK have a diagnosable mental disorder, with rates of psychosis in excess of 20 times the national average. Mental health problems account for 35–45% of absenteeism from work, at a cost to Europe of €136.3 billion in 2007 (ECNP, 2009; OECD, 2012). Overall costs of mental disorder in the UK have grown from £77.4 billion in 2003, to £105.2 billion in 2009 (CMH, 2010).
Such a combination of growing need and perceived problems with the effectiveness of existing healthcare is fertile ground for innovation. The response from the biomedical research community has been to repeat the pattern from 30 years ago, and make a renewed emphasis on building more biomedical and neuroscience capacity on the basis of familiar promises and prospects. For example the MRC (2010) review notes that there is “low research capacity” in the field.
However an alternative approach originating in the USA in the 1990s has grown rapidly and vocally to fill the gap. This approach is based on the concept of ‘recovery’. Recovery means the right to a life that has meaning and satisfaction as defined by the person themselves, even if their mental health problems cannot be eradicated. Recovery originated as a grass-roots movement in the USA (Davidson, Rakfeldt and Strauss, 2010). It has spread with enormous energy throughout the English-speaking world (US, NZ, Aus, UK), and is under serious discussion in Europe (Samele, 2012; WHO, 2005). It is increasingly supported by professional, third sector and activist movements, and has very recently appeared in both the latest UK Department of Health policy No health without mental health (2011) and the US Federal government’s Substance Abuse and Mental Health Administration policy (SAMHSA, 2011). For example SAMHSA defines recovery in four parts:
- health – managing one’s disease(s) and living in a healthy way;
- home – a stable and safe place to live;
- purpose – meaningful daily activities, such as work, with the independence and resources to participate in society;
- community – relationships and social networks for support, friendship, love, and hope.
The emergence of recovery originated as a social movement by those experiencing mental health difficulties, but it has since been adopted by mental health professionals, and more latterly incorporated into the policy framework of government health and social care departments. Although the SAMHSA definition is typical of the field, weaker meanings of recovery have been promoted by different professional groups as a way of accommodating their existing activities and interests, such that there are now three definitions or types of recovery used within the mental health field, ranging from weak to strong:
- as a reduction of medical symptoms (recovery RI), frequently stressed by medical staff.
- as the complete redefinition of the meaning of mental disorder, and the instillation of hope for a better life (recovery RIII), increasingly used by service users and their representatives.
- as rehabilitation, mainly employment (recovery RII), often used by nursing and social care staff.
Relevance of social science
Social science has a long tradition of work in the field of mental health. The earliest work analysed the aetiology of mental illness in relation to major social patterns such as urbanisation and social inequality. At that time most mental health sufferers were placed in large hospitals, and these institutions also furnished a rich source of sociological data about the structures and dynamics of large organisations. Fundamental developments in interactionist sociology on identity, group life, power negotiations, and grounded theory were made by Goffman, Strauss and others. Labelling theory and stigmatization, developed in the work of Scheff (1999) and others, founded a research tradition that was subsequently applied to the sociology of crime, youth culture, and race. Much of this crossed to the UK to inform studies of organisations, deviancy, work, and the professions, but despite an interdisciplinary interest in resilience, wellbeing and happiness, there has been far less social science research in the mental health field in the last 20 years.
In other related areas there have been major new research avenues explored, such as the sociology of physical health and illness, and the sociology of the body. Medical sociology is by far the biggest sub-field of any in sociology, and yet almost none of its work focusses on mental health. For example studies of doctor – patient interactions, the nature of diagnostic practices and meanings, and the anthropology of symptoms, have made major advances in our understanding, yet little of this work has crossed over into the mental health field. Some examples would be Kleinman’s (2011) work on the somatisation of human suffering, and the way in which anthropology alerts us to the cultural relativity of biomedical concepts, and Busfield’s (2011) recent argument that the diagnosis of mental illness is becoming over-extended. Of closer relevance to recovery is Crossley’s (2006) research into oppositional movements by service users and the way these are structured in common with pressure groups and political movements.
However these examples are notable exceptions in relatively quiet field. An important task therefore is to gather data on the way in which all three different definitions of recovery are used and promoted in the ‘recovery society’. We need a detailed examination of the way in which this term has developed, the way it is being widely introduced in practice, the experiences of mental health service users, and the methodological issues involved in gathering and assessing data about it. We should bring social science back into this field by the careful and critical investigation of recovery which is based centrally on a social aetiology, and the novel use of powerful social technologies, for example: Pahl’s work on friendship, personal communities and ‘social convoys’ (Pahl, 2000; Spencer and Pahl, 2006); Hacking’s analyses of ‘making up people’ and the ‘looping effects’ of mental disorder categories (Hacking, 2007); and research on ‘successful’ lives of both the profoundly impaired and the rich (Pascall and Hendey, 2001; Pahl, 1995).
There is today an unprecedented opportunity to re-think the nature of mental disorder, its health and social care, the experiences of those struggling with it, and the application of these findings to wider areas of long-term health conditions.
Bloom, D.E., et al (2011) The Global Economic Burden of Non-communicable Diseases. Geneva: WEF
Busfield, J. (2011) Mental Illness Cambridge: Polity Press.
CMH (Centre for Mental Health) (2010) The economic and social costs of mental health in 2009/10
Crossley, N. (2006) Contesting Psychiatry: Social movements in mental health London: Routledge
Davidson, L., Rakfeldt, J and Strauss, J. (2010) The roots of the recovery movement in psychiatry Wiley
DH (UK Department of Health) (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages Gateway Ref 14679, HMGov
ECNP (European College of Neuropsychopharmacology) (2009) 22nd Congress, 12 Sept, Istanbul
Goffman, E. (1991) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates Penguin.
Hacking, I. (2007) ‘Kinds of people: moving targets’ Proceedings of the British Academy 151, pp. 285-318
Kleinman, A. (2011) ‘Four social theories for global health’ The Lancet 375, 9725, pp 1518-1519
Lees, J., Manning, N., Menzies, D. and Morant, N. (2004) A Culture of Enquiry: research evidence and the therapeutic community, Jessica Kingsley Publishers
MRC (Medical Research Council) (2010) Review of Mental Health Research London: MRC
OECD (2012) Sick on the Job? Myths and Realities about Mental Health and Work. Paris:OECD
Pahl, R.E (1995) After Success. Fin-de-Siècle Anxiety and IdentityCambridge: Polity Press
Pahl, R.E. (2000) On Friendship Cambridge: Polity Press
Pascall, G. and Hendey, N. (2001) Disability and Transition to Adulthood: Achieving independent living Brighton/York: Pavilion/Joseph Rowntree Foundation
Pilgrim, D. and Rogers, A. (2009) Sociology of Mental health and Illness Buckingham: Open University.
SAMHSA (US Federal Substance Abuse and Mental Health Administration) (2011) at http://www.samhsa.gov/newsroom/advisories/1112223420.aspx
Samele, C. (2012) European Profile of Prevention and Promotion of Mental Health (EuropPoPP/MH), Brussels: EU Executive Agency for Health and Consumers.
Scheff, T.J. (1999) Being Mentally Ill, A Sociological Theory New York: Aldine de Gruyter
Spencer, L. and Pahl, R. (2006) Rethinking Friendship Princeton University Press
WHO (2005) Mental health: facing the challenges, building solutions. Copenhagen: WHO
Wilkinson, R. and Pickett, K. (2010) The Spirit Level: Why Equality is Better for Everyone Penguin.