How Do We Understand Mental Health?

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How Do We Understand Mental Health?

• In search of an integrating conceptual framework
• Jerry Tew, School of Social Policy

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What is positive mental health?
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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).

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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

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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?

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• How does it start to go wrong?

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HOW DO WE TEND TO THINK ABOUT AND RESPOND TO
MENTAL DISTRESS?
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THE BIOPSYCHOSOCIAL MODEL
BIO
PSYCHO
SOCIAL
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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

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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

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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

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Starting to deconstruct A bolt out of the blue

• Service user perspectives
• Finding meaning in distress experiences / making
  connections
• New language
• Reclaiming recovery life with purpose and
  meaning empowerment and control
• not symptom-free
• Hearing voices not schizophrenia CASL

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Different ways of viewing mental distress

• Symptoms of an underlying illness
• 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.
• A coping or survival strategy
• the best available way of dealing with painful or
  stressful experiences.

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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

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What makes us vulnerable to experiences of mental
distress?

• Life events e.g. Trauma, abuse and neglect

• Social context e.g. inequalities,
  discrimination

• Genetics

• Family dynamics and relationship difficulties

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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)

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Life events Trauma, abuse, neglect

• Majority (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)

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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)

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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
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A word of caution

• We have a lot evidence as to what may be
  contributory factors
• BUT
• Presence of these factors does not automatically
  mean that person will go on to experience mental
  distress

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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

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Beyond the illness model alternative models of
understanding

• Social model of disability
• Stress / vulnerability
• Social / trauma
• Powerlessness / empowerment

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Social model of disability

• Emerged from disabled peoples movement
• Shifts focus from individual pathology / tragedy
  / self-blame
• Conceptual separation of impairment (physiology)
  and disability (what person is prevented from
  doing / being part of)

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Social model of disability

• What is experienced as most disabling is not
  peoples 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.

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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?)

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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

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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

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Stress / vulnerability model (Zubin and Spring)

• Vulnerability
• Social contexts
• Life events
• Genetic

• Current stress
• Transitions
• Responsibilities
• Boredom

• BREAKDOWN

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But we have strengths and resources as well as
vulnerabilities and stresses
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Current stressors
Social capital
Likelihood of mental distress
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SOCIAL / TRAUMA MODEL

• Forms of mental distress as logical responses
  to traumatic circumstances and their longer term
  social implications
• (Plumb, 2005)

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SOCIAL / TRAUMA MODEL
ABUSE
LOW SELF ESTEEM
DEPENDENCY
ABUSIVE RELATIONSHIPS
GUILT/ SHAME
DEPRESSION
OCD
SELF- HATE
NEED TO CONTROL
SOCIAL ISOLATION
ANOREXIA
ANGER
DISSOCIATION AND PTSD
SELF HARM
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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

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Recovery as empowerment

• Enabling people to take charge of their life
  again
• Doing with not doing to
• Focus on strengths and resilience
• Challenging stigma and discrimination
• (Re)negotiating the terms of relationships
• Maintaining / promoting social inclusion.

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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.

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Putting it all together (1)The build-up

• Social contexts and life events
• (involving oppression or powerlessness)
• LEAD TO
• Psychological adaptations
• (vulnerabilities and resilience)
• AND
• Physiological adaptations
• (hard wiring and hormone levels)
• AND
• Social adaptations
• (relationship strategies, lifestyle, social
  capital)

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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

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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

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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