Mental Health at the Crossroads

The Promise of the Psychosocial Approach

Janet E. Williams, Shulamit Ramon, Shulamit Ramon

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351918138
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

This book is a challenge to the enduring status and domination of bio-medical approaches in mental health services. Contributors from four continents argue that this domination, along with modernization and multidisciplinary work, will not improve people's lives unless social and psychological perspectives are appreciated and integrated. This implies new forms of relationships and social arrangements. Mental Health at the Crossroads: the Promise of the Psychosocial Approach is a timely analysis of the psychosocial approach as it resonates across the discipline divide, considering the past and future development. It is written from the perspectives of service users and carers, managers, practitioners, educators, researchers and policy makers, illustrated with case studies from Australia, Brazil, Italy, UK and the USA. This book presents an alternative approach to conventional thinking in mental health, providing a fascinating and valuable resource for those seeking new perspectives, grounded in theory with practice examples, in order to influence the current agenda and change practice.

PART one
Mental Health at the Crossroads

1
Towards a Conceptual Framework

The Meanings attached to the Psychosocial, the Promise and the Problems

Shulamit Ramon and Janet E. Williams

Alice is a good looking woman in her early 30s, who has given recently birth to her second child, and is ‘mildly’ depressed. In conversation with the health visitor she lists the reasons why she should not be depressed, weepy and lethargic, ending the list by saying ‘I know that I am ungrateful for all that I have got and undeserving of it, but I still am depressed’. She described her lack of joy in having the new baby, in being with the older child (now five-years-old), of finding it increasingly difficult to get up in the morning, to get the children dressed, the house in order, of only wanting to stay in bed covered by a blanket, on her own, of being unresponsive to her partner’s wishes and needs, of finding what people talk about too trivial and of no relevance to her life. She is also worried about being a good enough mother and cannot imagine herself going back to work.

She did not experience depression after the birth of her first child, has a satisfying – but demanding – job to go back to, a supportive but weary and easily irritable partner, has no friends in the neighbourhood to which they have moved six months ago.

It would be easy to prescribe her antidepressants and tell her she will feel much better when the tablets will kick in within three weeks. Such a response will be perceived as a confirmation that the pregnancy and birth have led to a chemical imbalance, corrected by the drugs. This would leave untouched the issues of why has this reaction did not take place after the first birth, her fears for the future, the apparent isolation, her fragility, or the fact that the ‘mild’ depression is experienced by her, her partner – and no doubt her children too – as a very unhappy state to be in.

If, instead, Alice would be given access to a help line volunteer, a weekly group of women at different stages of postnatal depression to join, to which a creche is attached, with the option to take the antidepressants or not, she may have as a result a support network, an opportunity to discuss her issues within an empathic setting, listen to the issues and solutions raised by others, and make a much more informed decision as to whether she needs medication, counselling, to go back to a half-time post and when, what helps her when weepy, and perhaps increase the enjoyable elements of her life.

At present Alice is much more likely to be given only antidepressants. It is a matter of luck whether her GP will know of a help line, whether s/he will even consider the usefulness of such an alternative, or whether the health visitor will raise this possibility with her and her GP.

A paradigm shift in the context of mental health is in existence when we begin to doubt whether the usefulness of the existing hegemonic paradigm is over taken by its un-usefulness – either/or conceptually, methodologically, ethically, and in everyday intervention. The harm seems to outweigh the benefit attributed to such an approach; when central planks of the issues at stake are not taken into account – or denied attention – by that hegemonic paradigm according to major stakeholders; the beginning of an alternative perspective is delineated.

We would be arguing in this book that indeed we have reached this state of doubt concerning the hegemonic model of mental health, namely the ‘medical’ model, or more correctly the biochemical model of mental illness. The issues denied prominence and due attention form a long list, including themes such as:

• • The social context and its variables
• • Health as distinct from the absence of illness
• • The psychological layer as an etiological factor, including the impact of abuse
• • Power relationships and their impact within the mental health system and in its wider social context
• • Recovery as a realistic option for people with psychosis.

The continuous invention of new types of medication, some with fewer side effects than the previous generation and hence more effective in suppressing symptoms and enabling people to lead a more ordinary life, is presented as the proof that the biochemical model is working well and should not be discarded.

No one would wish to deny relief to people who suffer relief from pain. Yet it needs to be asked at what cost to them – and to the rest of us – is this relief obtained. Is it long lasting? Have the alternatives been given a fair trial? If Alice would take the medication prescribed would she be able to stop taking it at the end of the period prescribed by her doctor, or would she become dependent on it?

Why, despite these achievements, more and more people – lay and professionals alike – are raising their doubts as to the validity and effectiveness of the medical model (Rogers, Pilgrim and Lacey, 1993; Ramon, 2003)?

In typical relationships between doctors and patients or nurses and patients, the latter are often grateful for the professional intervention offered by the first. Yet fewer of those using mental health services express such gratitude. When asked, users would indicate that they have met good and bad practitioners; highlighting that the difference between the two is not about their professional ability but whether they treated the user as a person, whether they felt respected, cared for and attended to as a human being. This response, especially expressed in the context of in-patient facilities, reflects some of the key differences between medicine and psychiatry. Users of mental health services can easily be seen as needy of, or greedy for, attention, due to being in turmoil, feeling a failure and being rejected by others, especially when in crisis. They therefore seek to be compensated for the above in the contact with professionals, but often feel rebuffed. While some of the difficulties in the relationships are related to lack of enough workers able to provide good enough attention, it is also true that medicine – of which psychiatry is a branch – trains professionals who focus on the part that needs to be cured, while being polite and courteous. Being polite and courteous is insufficient in terms of the type of attention the sufferer from mental distress or illness wishes for and requires. This way of relating to people implies that professionalism is not about a distanced, ‘hands off’ approach, but instead requires emotional closeness, a ‘hands on’ approach, and the demonstration of interest in those everyday affairs which matter to the service user. Alice felt truly relived when the health visitor asked her to tell her in detail about getting up in the morning and preparing the children for the new day, and even seemed genuinely interested in what she had to tell. It was the first time that a professional showed an interest in what she found particularly difficult, but could not bring herself to discuss as it was ‘so trivial’, and she was sure none of the professionals would be interested.

Providing satisfactory care in mental health is a mentally and psychologically demanding activity, one which requires considerable time, continuity and hence a sufficient number of sufficiently qualified people to carry it through adequately. The ‘hands on’ approach which enables the client to get on with her/his life, the shortening of the distance between professionals and users, and the demonstrable emotional availability of the worker is what marks good psychosocial professionalism from the traditional model of practising psychiatry.

Although low in technological costs, mental health services are bound to be financially expensive because they are labour intensive, and will need to be largely met through public sector funding. Nevertheless, there are significant differences as to the cost of different forms of interventions and policies, with hospital care being the more costly setting.

The critique of the medical model in the context of mental health has focused on its denial of the existence of the impact of the social context in leading to mental distress, in interacting with any biological or psychological intervention, and therefore in impacting on recovery too. This critique is not new; its hay day dating back to the 1960-1980s. The core of that critique has been since accepted as valid, yet most of it has been neatly ignored by the protagonists of the medical model and those circles impacted by them. This attests to the power of the medical model within and outside the mental health system, and the relative lack of power of the protagonists of the critique. It also reflects the degree of discomfort this critique causes to those who are in the position of acting upon it.

For example, we are witnessing now the introduction of mental health teams to primary care, staffed by nurses with skills in brief psychological interventions, for which there is a convincing evidence base of the likely benefit to the many people approaching primary care presenting the first signs of depression and other types of minor mental illnesses (Armstrong, 1995). Likewise early psychosocial intervention in psychosis is proving to be a valuable intervention (Jackson and Farmer, 1998, and chapter 11 by Jones and Gamble in this text), as are attempts to work within a psycho-educational model with families (Falloon and Fadden, 1992). This new way of working reflects the recognition of the value of psychological interventions, as distinct from – though not in opposition to – the medical model. It attests to the acceptance that medication for these types of difficulties is, at best, of limited value because it does not enable the person to develop better problem solving and coping strategies, but instead fosters a denial of the implications of the symptoms and their meaning in the person’s context.

Yet the same approach to mental health in primary care is taken regardless of whether the practice is based in a run down or a posh area; ignoring the level of poverty, isolation, and socio-economic deprivation to be found in a poor area to which clients return from the brief intervention.

A new national initiative regarding the reduction of domestic violence, because of its damage to the mental health of women and children, started in 2002, yet the connection between domestic violence, minor and major mental illness was not made and the most recent interventions for the latter are not informed by the former.

No attempt is made to take account of these structural factors and handle their impact as appropriate to different populations, reflecting the fragmentation between psychological and social perspectives, and the fragmentation in the level of acceptability of each of those approaches within the medical establishment. Existing evidence of the usefulness of individual and group social work intervention in primary care, pioneered in the UK in the 1960s and 1970s, has been ignored (Knight, 1978; Brewer and Lait, 1982), highlighting the selective use of existing evidence in favour of approaches which discomfort the protagonists of the medical model as little as possible, aimed at reducing pressure on GPs above all other objectives.

Simultaneously we have seen the revival of interest in mental health promotion and formulation of policies related to it, though without the necessary funding for their implementation, in a number of countries, such as Britain and Australia, for reasons explained in the chapters on contextualized social policy and the chapter on mental health promotion. On the one hand these provide a blueprint for the promotion of mental health in the context of reducing discrimination and social exclusion (see the British National Service Framework for Mental Health, DoH 1999). Schools and the workplace are cited as the sites of promising such interventions. On the other hand these policies extend the remit of psychiatry, and its social control mandate, even further than is the case presently. This duality of a liberating force, which can also be oppressive, is inherent within the mental health system, and is not unique to its mental health promotion component (Rose and Miller, 1986; Pilgrim and Rogers, 1999).

The inclusion of mental health promotion in the context of discrimination and exclusion, the increased focus on the value of employment, and the belief in the ability to work of people with long term mental ill health are some of the signs that at long last the critique of the medical model is finding its way into the official platform of the priorities to be achieved in – and by – the mental health system. The official platform has been composed in all Western countries with the collaboration of all mental health disciplines, as well as that of users and carers, led by psychiatrists able to put together the psychological and the social perspectives side by side with a version of the medical model. Whether this version has coherence, and whether there is coherence in separating out the social from the psychological, is one of the issues to be explored in this book. The shift in the official platform reflects the shift in the paradigm which underlined the mental health system up to this point in time.

We, and all of the contributors to this volume, would wish to argue that the split between the social and the psychological risks would turn the achievement of putting the two on the policy map into an empty victory, which would reinforce the denial of the interactive relationships between these two dimensions by the purists of the medical model.

Some of us – notably Duncan Double – are wishing to reconstruct the biopsychological model, initially proposed by the German-Jewish, American, psychiatrist Adolph Meyer in the early part of the 20th century. Arguing that biology plays a part in mental distress, illness and health seems commonsensical for creatures rooted within a body, as we all are. Yet in the history of the medical model giving priority to biology has meant the denial of all else as of primary importance, a position the contributors to this book would disagree with for reasons outlined in a number of the chapters, ranging from the chapter on risk, through the chapters on self-defining scenarios and the recovery narrative, to the chapters on spirituality, self-help, and trauma. As a result, few of the authors to this collection would wish to see the biological dimension given the same priority as the social and psychological ones, but the argument for such a perspective will be outlined in this collection, enabling the reader to make his/her own judgement as to its viability. However, it is important to note that contributors to this book differ among...