How Do We Understand Mental Health?

1. How Do We Understand Mental Health? In search of an integrating conceptual framework Jerry Tew, School of Social Policy

2. What is positive mental health?

3. 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).

4. 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

5. 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?

6. How does it start to go wrong?

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

8. THE BIOPSYCHOSOCIAL MODEL BIO PSYCHO SOCIAL

9. 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…

10. ‘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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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)

17. 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)

18. Family dynamicsand 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)

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

20. 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

21. 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

22. Beyond the illness model: alternative models of understanding • Social model of disability • Stress / vulnerability • Social / trauma • Powerlessness / empowerment

23. Social model of disability • Emerged from disabled people’s 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)

24. 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.

25. 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?)

26. 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” – RoyPorter

27. The Triple Whammy • The experience of mental distress (which may connect with experiences of discrimination and abuse) • Stigmatising responses from friends, family, professionals and society at large • Responses can make mental distress worse

28. Stress / vulnerability model (Zubin and Spring) Vulnerability • Social contexts • Life events • Genetic Current stress • Transitions • Responsibilities • Boredom BREAKDOWN

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

30. Vulnerability Resilience + + Current stressors Social capital Likelihood of mental distress

31. SOCIAL / TRAUMA MODEL Forms of mental distress as logical responses to traumatic circumstances and their longer term social implications (Plumb, 2005)

32. 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

33. 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

34. 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.

35. 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.

36. 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)

37. 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

38. 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

39. 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