How Do We Understand Mental

Health?

In search of an integrating conceptual framework

Jerry Tew, School of Social Policy

What is positive mental health?

Some approaches

Absence of illness (WHO)

Happiness (Layard)

Resilience (Positive Psychology - Seligman) - not just capacity to experience positive emotions, but

also engagement in relationships and activities that provide meaning

Affirmative relationships, identities and statuses Connectedness: ‘a place in the world’ Mentally healthy families, communities… Inverse relationship between mental health and

inequality, status competition and ‘in your face’ relative deprivation – and this affects everyone (Wilkinson).

Theorising mental health

Mental health is dynamic A process, not a state

It arises through, and enables, positive interactions between the personal and the social It is relational and is not just a property of

the individual Our genetics may predispose us to have a

more active engagement with our social environment

Idea of a virtuous circle

Concepts that link the personal and the social aspects of mental health

Efficacy and engagement Capabilities Resilience Relationships and mutuality Valued identities and statuses Social contexts Access to opportunities Meaning, purpose and value

Implications for education?

How does it start to go wrong?

HOW DO WE TEND TO THINK ABOUT AND RESPOND TO MENTAL DISTRESS?

THE BIOPSYCHOSOCIAL MODEL

BIO PSYCHO SOCIAL

Dominant story ‘A bolt out of the blue’

A person is hit by a biochemical event that

impacts on how they think, feel and behave

and has implications for their family life, employment, housing needs…

‘A bolt out of the blue’ cont.

So, if we treat the illness, the rest will sort itself out (with some help and support)

Or, they have a chronic illness and will require ongoing care and surveillance

Some implications of ‘A bolt out of the blue’

People are powerless to do much about mental distress – except for accepting medical treatments Culture of compliance

Experiences of mental distress have no meaning – just symptoms of an illness

No connection with ideas of positive mental health

Starting to deconstruct ‘A bolt out of the blue’

Service user perspectivesFinding meaning in distress experiences

/ making connectionsNew language:

Reclaiming ‘recovery’ – life with purpose and meaning; empowerment and control

– not ‘symptom-free’ ‘Hearing voices’ not ‘schizophrenia’ –

CASL

Different ways of viewing mental distress

1. Symptoms of an underlying illness2. An expression of an unresolved

‘problem of living’. a cry for help in relation to ‘unliveable' past

and/or present social circumstances A way or expressing the inexpressible.

3. A coping or survival strategy the best available way of dealing with painful or

stressful experiences.

Making sense of mental distress:

Evidence from research

What do we know about causation?What do we know about what promotes

recovery?

Co-constructing knowledge with service users and carers

What makes us vulnerable to experiences of mental distress?

Life events e.g. Trauma, abuse and neglect

Social context e.g. inequalities, discrimination

Family dynamics and relationship difficulties

Genetics

Social context

Disadvantage, social stress and inequality Poor educational attainment, unemployment (Fryer, 1995) Being brought up in a poor and socially disorganised

neighbourhood (Fryers et al, 2001; Harrison et al, 2001) relative inequality (Dohrenwend, 1998).

Discrimination and identity issues (Janssen et al, 2003) Race

higher incidence of ‘schizophrenia’ in UK but not in Jamaica (McGovern and Cope, 1987; Fearon et al, 2006)

‘ethnic density effect’ (Boydell, 2001) Gender / sexuality – over-conformity to or rebellion

against gender stereotypes (Read, 2004)

Isolation / social exclusion Defeat and entrapment (Gilbert and Allan, 1998)

Life events: Trauma, abuse, neglectMajority (but not all) of experiences of

mental distress link to prior traumatic life events, e.g. Sexual or physical abuse Loss of parent or significant other Emotional neglect

Relationship holds for all forms of mental distress (depression, self-harm, psychosis…)(Read et al 2004; Larkin and Morrison 2006)

Family dynamics and relationship difficulties

Longitudinal studies: family dynamics not genetics as best predictor of breakdown (Tienari et al, 1994)

‘Expressed emotion’ and relapse (Kuipers et al, 1992)

Unresolved conflict, covert hostility, distorted communication patterns (Bateson, Lidz)

Genetics: interaction with social factors (Tienari et al, 1994)

Genetic risk Family dynamics

Diagnosed with schizophrenia in later life (%)

Low ‘Healthy’ 0

High ‘Healthy’ 1.5

Low ‘Dysfunctional’ 5

High ‘Dysfunctional’ 13

A word of caution

We have a lot evidence as to what may be contributory factors

BUTPresence of these factors does not

automatically mean that person will go on to experience mental distress

What influences recovery rates? (Warner 1994)

No correlation between introduction of medical treatments and recovery rates

What seems to matter is having a ‘place in the world’ to recover into

Strong positive correlation with employment rates (recent UK rates lagging, probably due to benefits trap)

Cultural acceptance / expectation of recovery – e.g. Kerala

Beyond the illness model: alternative models of understanding

Social model of disabilityStress / vulnerabilitySocial / traumaPowerlessness / empowerment

Social model of disabilityEmerged from disabled people’s

movementShifts focus from individual pathology /

tragedy / self-blame Conceptual separation of impairment

(physiology) and disability (what person is prevented from doing / being part of)

Social model of disability

What is experienced as most disabling is not people’s impairment, but societal responses to it.

These responses may be framed by a construction of ‘normality’ that puts down, patronises or excludes those who fall outside its definition - othering.

How does the model fit in relation to mental health?

For many people, societal (and professional) response to mental distress at least as problematic as distress itself

HOWEVER Many people would not see their

mental distress as a physiological impairment (do we buy into the medicalisation of distress?)

What is so threatening about mental distress?

‘Hysterical’ societal reaction:

Demonisation of mentally distressed as “a menace to the proper workings of an orderly, efficient, progressive, rational society” – Roy Porter

The Triple Whammy

1. The experience of mental distress (which may connect with experiences of discrimination and abuse)

2. Stigmatising responses from friends, family, professionals and society at large

3. Responses can make mental distress worse

Stress / vulnerability model (Zubin and Spring)

Vulnerability Social contexts Life events Genetic Current stress

Transitions Responsibilities Boredom

BREAKDOWN

But we have strengths and resources as well as vulnerabilities and stresses

Vulnerability

Resilience

Current stressors

Social capital

Likelihood of mental distress

+ +

SOCIAL / TRAUMA MODEL

Forms of mental distress as logical responses to traumatic circumstances and their longer term social implications

(Plumb, 2005)

SOCIAL / TRAUMA MODEL

ABUSE

ANGER

SELF-HATE

GUILT/SHAME

NEED TO CONTROL

LOW SELFESTEEM

DEPRESSION

SELFHARM

OCD

ANOREXIA

DISSOCIATION AND PTSD

DEPENDENCY

ABUSIVE RELATIONSHIPS

SOCIALISOLATION

Powerlessness / empowerment

Exposure to situations of unequal power underlie: Disadvantage and discrimination Trauma and abuse Defeat and entrapment

Current powerlessness leads people to internalise and reproduce these relations as forms of mental distress (e.g. self harming, hearing ‘bad’ voices) Inability to control aspects of self mirrors

inability to control external events

Recovery as empowerment

Enabling people to take charge of their life again

‘Doing with’ not ‘doing to’Focus on strengths and resilienceChallenging stigma and discrimination (Re)negotiating the terms of relationshipsMaintaining / promoting social inclusion.

Reconceptualising the relationship between the social and the medical Experience of trauma and adverse social contexts

can impact on hard-wiring and biochemistry of brain – evidence from MRI scans

Exposure to new social environments may enable the brain to re-align pathways and biochemistry – but this may take time

Medication can work for some people as a way of managing certain extremes of their distress – but may also get in the way of recognising and resolving

underlying issues.

Putting it all together (1):The build-up

Social contexts and life events(involving oppression or powerlessness)

LEAD TOPsychological adaptations (vulnerabilities and resilience)

ANDPhysiological adaptations

(hard wiring and hormone levels) AND

Social adaptations (relationship strategies, lifestyle, social capital)

Putting it all together (2): Tipping the balance

Whether a potentially challenging situation may trigger an episode of mental distress may depend on:

Our adaptations (psychological, physiological and social)

Our access to social resources Other stresses we may be dealing with at the

same time

Putting it all together (3):Supporting recovery

Developing a shared framework of understanding Holding and managing out-of-control aspects of

experience Learning new strategies Using medication if it works (preferably short-term)

Making new adaptations Building on strengths and resilience Acknowledging and (sometimes) resolving issues that

are contributing to vulnerability Learning new ‘strategies of living’

Reclaiming power and control

Some implications and conclusions

If we are to move beyond ‘a bolt out of the blue’

People with lived experience must be co-constructors of any new conceptual frameworks

Positive mental health, resilience and recovery are core to the agenda

Any framework of understanding must encompass the interaction between the personal and the social