Mental Health in Crisis

Joel Vos, Ron Roberts, James Davies, Author

• Publisher: SAGE Publications Ltd
• Year: 2019
• Print ISBN:
  9781526492203
• Edition: 1
• eBook ISBN:
  9781526492609
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

At a time of huge pressures on mental health services, this highly topical, broad-ranging and thought-provoking analysis of the mental health crisis examines the current challenges in mental health service delivery and access using a range of perspectives (political, economic, and cultural, organisational issues). It then puts forward a number of alternatives, reviewing both current and alternative initiatives, and exploring what is needed for a mentally healthy society.

1 Community Crisis

Joel Vos

Modern man no longer communicates with the madman … There is no common language … The language of psychiatry, which is a monologue by reason about madness, could only have come into existence in such a silence.

Foucault, 2003: 5

The Copernican Revolution in Mental Health Care

In modern history, individuals with mental health problems have often occupied a difficult place in their communities (Foucault, 2003). This chapter describes the complex relationship between individuals with mental health problems and society. We will argue that a Copernican revolution is in our midst, with individuals less likely to be treated as pariahs against whom society should be protected. Instead, it is society which is now seen as oppressive and stigmatising and individuals more often supported within their communities. The role of mental health care is transforming from individual-oriented to social-context-oriented care. However, structural injustices persist.

The history of individuals with mental health problems opens with a dark chapter. Until the late European Middle Ages, people lived their lives according to the expectations of their social context – family, church and landlords. When their well-being prevented them fulfilling expected roles, their lives were deemed meaningless (Vos, 2018). Mental health problems were seen as moral issues which prevented individuals realising their pre-ordained station in the socio-cosmic-divine order. Problematic behaviours were deemed ‘evil’ and individuals designated as sources of malign contagion became outcasts, sent away to colonies or under due legal process burned at the stake. The ‘lucky’ were ‘taken care of’ in religious madhouses, such as Bethlem, which was set up to care for patients in London in 1377.

The medical profession began to conceptualise mental health problems as physical afflictions from the 17th century onwards, establishing numerous ‘madhouses’ in England. Following the Lunacy/Lunatics Act 1845, a network of country asylums was built. Little treatment existed in these, which were effectively ‘warehouses for the unwanted’ (Glasby & Tew, 2015: 29). Bethlam became a tourist attraction, with over 100,000 annual visitors seeing the patients in cages. Many asylum doctors argued that mental vulnerability was caused by tainted genes, a then common view. During the 19th century, doctors began experimenting with ‘cures’ – lobotomy, electro-convulsive therapy, drugs – which owed more to trial-and-error than scientific evidence.

At the same time, philosophers developed the idea that our psychological experiences are not necessarily biophysical in origin but the result of our ways of reasoning and psychological associations. At the end of the 19th century, Freud instigated the ‘talking cure’ to help individuals. Instead of the asylum, patients saw him in his home. Like his contemporaries, Freud focused on the individual not the social context. Initially he considered clients had developed neuroses because of traumatic childhood experiences such as incest. Later however, he recanted, arguing that so many reported similar experiences that not all of them could be real. He subsequently developed his theory of the Oedipus complex, holding that patients’ reports of abuse were incest fantasies.

Freud’s theories contributed to the individualisation and psychologisation of real-life experiences, a common tendency within the nascent discipline of psychology. Skinner and Pavlov, in turn, demonstrated how animals and people create psychological associations, for example between a bell ringing and the delivery of food when both occur at the same time. The sound of the bell develops the meaning of ‘food’ for the animal, although this does not objectively indicate food. In this behaviourist paradigm, mental health problems are seen as the result of conditioning and reinforcement. Behaviour therapy came to focus on analysing individual association patterns and learning new behaviour.

In their early versions, all three paradigms – medical, psychodynamic and behaviourist – located the cause and solution of mental health problems in the individual. This assumption has long determined the diagnosis and treatment of ‘mentally-ill patients’. Mental health services were designed to cure individual pathologies, attention rarely being given to clients’ subjective experiences as their views were considered pathological and irrelevant. Because of this, patients were disbelieved when they spoke about abuse in their family, community, church or hospital. Criticisms about mistreatment in psychiatric clinics also seldom reached a general audience, enabling mistreatment to continue. As Smail (1987: 69) argues, such beliefs about ‘the reasons for our conduct’ are ‘designed to repress’; we then ‘come to feel’ personally responsible ‘for social injustices’ perpetuated ‘beyond the reach of our awareness’.

Community Psychology

Influenced by the First World War, Freud returned to the idea that the wider context could influence mental health. Jungian analysis, which emphasised universal archetypical experiences, and philosophical analysis of our shared existential struggles, added to the growing interest in the common conditions of our lives. ‘Shell shock’ in soldiers returning from the front came to be seen as unrelated to one’s biological constitution or internal psychodynamics. Recognition of an external reality which influences people’s mental health, and that individuals shared common experiences, meant they were not completely to blame for their plight.

The British Mental Treatment Act 1930 supported out-patient treatment for mental health problems, funded by local authorities. The birth of the British National Health Service (NHS) in 1948 saw mental health services become more widely available, albeit underfunded. Financially and socially, this system appeared unsustainable, so by the late 1950s, the idea of treating patients in the community rather than hospitals began to grow. As asylums began closing psychotherapy clinics opened, meaning individuals received help from day care, social work support and sheltered employment. This deinstitutionalisation was due to a combination of factors: the development of new pharmaceutical and psychotherapeutic treatments which didn’t require hospitalisation; poor conditions in asylums; greater acceptance of individuals with mental health problems; and lack of funding. However, one of the most important factors was a different view on mental health and care – that individuals were not always to blame for their problems.

A critical psychiatry movement emerged, and films such as One Flew Over the Cuckoo’s Nest (1975) brought the power dynamics in psychiatric settings to public attention. Ronnie Laing, who listened and empathised with his patients in order to understand the logic of their experiences, was a significant figure in this movement, which spread beyond the UK. Franz Fanon, Paolo Friere and Steve Biko directed attention to the political context. So the idea evolved that people’s mental health could be understood within a wider social framework. During the 1970s, critical psychology emerged, influenced by the Frankfurt School and post-structuralism. The 1980s saw the emergence of community psychology in Latin America, situating the community as the focal point of psychological action.

These developments signalled a movement away from individuals toward the wider community, one seen as efficient, beneficial for mental health and empowering. This chapter will describe the shifts in thinking that underlay this transformation.

Individuals-in-Context

The ‘mentally ill’ were traditionally seen as victims of defective biology, conflicted psychodynamic drives or maladaptive learned behaviour. The social context was reduced to an ‘object’ or ‘stimulus’ that the individual responds to. However, theoretical developments in psychodynamics and behaviourism acknowledged the context of the individual as a primary cause of problems. Object-relation theorists, such as Klein and Winnicott, and attachment theorists such as Bowlby and Ainsworth, argued that individuals develop fundamental psychological patterns, such as insecure attachment, in response to early experiences. Behaviourists argued that operant conditioning (by reinforcement or punishment) could account for aberrant behaviour while others suggested a role for dysfunctional family dynamics.

Though the focus widened from the individual to their immediate social context, this did not imply that political struggles and socio-economic circumstances were seen as potential causes of problem behaviour. Ironically, numerous accounts exist of governments using mental health care to manipulate political opponents, branding them ‘mentally ill’ and exposing them to invasive ‘treatments’ such as electroconvulsive therapy (ECT). The American Central Intelligence Agency (CIA), for example, developed an instructional manual of how to mentally torture political opponents, whilst in the USSR dissidents were sent to asylums (Klein, 2007). Under the McCarthy regime in the US, supposed communists were also subjected to involuntary psychiatric treatments. Mental health care thus functioned as a domain of political repression. When the US army intervened in Chile, Brazil and Iraq, they brought with them numerous psychiatrists and other ‘behavioural science experts’ as members of their strategic force.

Paulo Freire (1970) was among the first to expose the political use of mental health. Though his work focused primarily on education, it has been extensively applied in mental health care. Freire considered all education either indoctrinates individuals into conformity or else becomes a practice of freedom enabling people to deal critically with their reality. Similar voices were heard in colonial countries, such as Algeria. The psychiatrist Franz Fanon (1952/1967) describes how black people were perceived as lesser beings by white people, and how this perception created feelings of insecurity and inferiority in black individuals. Fanon’s work inspired Steve Biko in the anti-apartheid struggle in South Africa and Malcolm X in the American civil rights movement. Their work showed how black people, ethnic minority groups and those without socio-political power are oppressed, not only in the practical/physical domain but also the psychological. Referring to such developments, Sedgwick (1982) concluded that mental health must be seen through a political lens, and appealed for collective responsibility for the care of people with mental health problems.

These authors and activists effectively laid the foundations for critical community psychology to examine the dominant narratives in psychology, and reveal how political and socio-economic circumstances shape both individual well-being and social justice (Kagan et al., 2011), and thus that the intra-personal, inter-personal and political-ideological domains cannot be clearly separated (Orford, 2008). They have since argued that to improve mental health, people’s politico-socio-economic circumstances should be enhanced, via individual empowerment, community action and mental health advocacy. An impressive body of research has strengthened their arguments.

From Nature–Nurture to Ecological Psychology

In the 1980s–1990s, the nature–nurture debate dominated mental health discourse. This concerned the respective contributions of genetic inheritance and upbringing/environment to mental health. The debate was often couched in Manichean terms, suggesting only one side could be right. Recent research suggests a more complex model involving the combined influence of genes, the physical and social environment, lifestyle and coping.

There is evidence to link genetic variations with diagnoses of schizophrenia (Tsuang et al., 1999), autism (Happé & Ronald, 2008) and mood disorders (Jacobson & Cryan, 2007). Although mental health problems may have biological correlates, they do not necessarily stem from them (Harré, 2002). Other physical factors are also influential. Having older parents or experiencing problems during pregnancy or birth increases the risk of developing schizophrenia (Matheson, et al., 2011), although some consider the risks may only impact those with specific genetic vulnerabilities. Particular genes may be ‘switched on’ in the presence of specific life events; for example, one genetic polymorphism is associated with depression later in life only when the individual has also experienced severe childhood trauma (Lok et al., 2013).

So psychological context shapes mental health, either alone or in interaction with biological factors. Philosophers have contemplated how societal trends can influence mental health; the present dystopia, characterised by widespread nihilism, narcissism and consumerism can influence how individuals develop (Levin, 1987). We will discuss later how social oppression has been linked with mental health problems. Numerous studies show psychosis and social disadvantage are correlated, leading to the hypothesis that powerlessness and subordination have biological and psychological consequences. Furthermore, the experience of blame or stigma may contribute to mental health problems. While situational and cultural circumstances may operate on a prior genetic vulnerability, research suggests that social, physical and economic circumstances influence mental health directly, with no underlying genetic vulnerability.

In addition to the factors described above, an individual’s lifestyle influences mental well-being. Smoking marijuana for instance increases risk of psychosis, whilst other drugs – including prescribed – may also create structural changes in the brain. What the long-term effects of these are remains unclear (Moncrieff, 2009). Researchers have also shown how individuals can experience an inner freedom and flexibility to cope in beneficial ways with difficult life situations. Similarly, people’s coping styles are important (Vos, 2018). In summary, mental health problems develop as a consequence of a complex combination and interaction of factors. This carries implications for interventions in different domains.

Fortunately, research shows that the brain is more flexible than previously thought. Later life experiences and life choices may also be critical to good mental health. Research shows that one’s personality significantly changes over the life course and that interventions, such as psychotherapy, can also change personality (Roberts et al., 2017). This research shows that individual and community mental health interventions have great potential.

Community psychologists have criticised mental health services for their narrow focus on the individual. For instance, many psychotherapeutic approaches address the individual’s experience of their life situation, although that situation may be unjust and a primary cause of problems. Psychotherapy individualises distress and ignores the complex real world in which we live (Smail, 2005). Mental health care systems have thereby been criticised for failing in their promise of progressive humanism (Pilgrim, 1997). Neglecting the wider parameters of human struggle, the psy-professions have intensified the gaze on individuals. The consequent self-blaming that can occur in psychotherapy can act as an additional burden.

From Universal Laws to Diversity

Elsewhere, we describe the unreliable scientific foundations of psychiatric diagnosis and note the influence of political lobbies on their development (Davies, 2013). Despite this, treatment is often based on such diagnoses and access to care is contingent on them. This diagnostic model also determines whether individuals will be recipients of coercive mental health care.

In recent decades, the universality of mental health categories has come under increasing fire. Phenomenologists argue that a mental health disorder is not an objective entity, such as a fever that can be reliably physically assessed. Mental health problems concern the way someone relates to their experiences and the situations they encounter. For example, when depressed you do not only see the world and others negatively, you feel and think negatively about yourself and your mental health, thereby affecting how you cope. As a result of this researchers have investigated ‘illness perception’, with different individuals having different ideas about mental health problems such as schizophrenia (Lobban et al., 2005). With different ideas about what it means to have a condition, people attribute their problems to different causes, have different ideas about its likely course and impact on their life, and what interventions may be appropriate. This subjective perception is often ignored in standardised mental health care. Humanistic and existential therapists reject the universality of diagnosis, and pay specific attention to individuals’ unique experiences.

There is increasing interest in mental health models in non-western peoples. The ways in which cultures differ from each other may have great relevance to perceptions of mental health, their causes and their treatments (Cox, 2018). Not only cultural differences influence ideas about mental health, but also subcultures (e.g. punks and hip-hoppers). We must be careful, however; cultural/subcultural identity and sense of self are not monoliths with one specific perception of mental health; individuals often experience different ‘selves’ in different contexts. This implies that no one-size-fits-all assessment of problems and solutions is adequate, and that listening, empathy and tailoring are core skills for practitioners. Research throughout the UK shows that using standardised treatment manuals is not more effective than tailored person-centred care (Truijens et al., 2018). Consequently, there is a movement away from universal assumptions towards embracing a diversity of voices in mental health. Unfortunately, NHS services remain dominantly focused on standardised interventions.

From Individual Cure to Social Recovery

The medical model suggests that mental health problems can be ‘cured’ on the basis of diagnosed psychopathology. Available data provides little support for this. Meta-analyses suggest that most pharmaceutical treatments produce ...

Table of contents

• Cover
• Half Title
• Acknowledgements
• Title Page
• Copyright Page
• Contents
• Introduction
• 1 Community Crisis
• 2 Austerity Crisis Psychologists for Social Change
• 3 The Financial Crisis in Mental Health Care
• 4 Biomedical and Drug Crisis
• 5 Diagnostic Crisis
• 6 Mental Health in Crisis
• 7 Existential Crisis
• 8 Crisis in Academia
• 9 The Organisational Crisis in Mental Health
• 10 Educational crisis
• 11 Visions for Mental Health Care
• References
• Index