Insight in mental illness and individualisation

1. Insight in mental illness and individualisation John Aggergaard Larsen European Institute of Health and Medical Sciences, University of Surrey Email: j.larsen@surrey.ac.uk Paper presented at the symposium ‘Sociology of Mental Health: Continuity or Change?’, BSA Annual Conference, 21-23 April 2006, Harrogate

2. Aims of paper • To argue that contemporary mental health treatment celebrates biomedical notions that ‘essentialise’ mental illness in the person and reflect individualisation in society • To argue that this ideology is presented and taught (‘socialised’) through complex sociocultural processes that require the critical attention of a sociology of mental health • To invite debate over the future empirical and theoretical investigation of these macro and micro processes – and their interplay

3. Trends in contemporary mental health treatment • Increased use of effective psychoactive medication (e.g. antidepressives, atypical antipsychotics) • Increased general popularity of ‘talking cure’–‘therapy culture’ (e.g. Furedi 2004) • Psychiatric awareness of need for holistic/integrated/-complex ‘biopsychosocial’ interventions to help people learn to ‘live with’ difficulties –‘recovery model’ (e.g. mental health outreach teams and early intervention in psychosis services) • Dominance of biomedical and psychiatric diagnostic language in mental health practice (e.g. Barrett 1996; Luhrmann 2000)

4. Empirical illustration of claims: Person-centred ethnographic study of early intervention in psychosis service in Copenhagen, Denmark • 2 years fieldwork over a 3.5 year period (1998-2001) in active membership role as project evaluator • Participant observation with staff and in therapeutic groups • Multi-method approach to illuminate perspectives of staff, clients and relatives: individual interviews, focus groups, attitude surveys, registration forms, written narratives • Repeated interviews with 15 clients over a 2.5 year period – and creative-expressive collaboration in book project (Larsen 2002, 2003, n.d.a; Sharkey and Larsen 2005)

5. The early intervention in psychosis service • Early intervention in psychosis for young people (18-35 years old) in Copenhagen – OPUS • Diagnosed within the ‘schizophrenic spectrum’ (ICD-10) • Two-year intensive ‘bio-psycho-social’ community outreach treatment and support through: low dose ‘atypical’ medication, case manager, family groups and social skills training • Cognitive behavioural therapeutic (CBT) approach • Focus on social rehabilitation

6. Therapeutic work focused on psychoeducation and cognitive behavioural therapy (CBT) to help clients: • gain ‘insight in illness’; • take their medication correctly (‘comply with’); • identify symptoms and respond appropriately; • learn and train social skills to be ‘well-functioning’ (velfungerende); • communicate with their families appropriately (low ‘expressed emotion’, EE) to strengthen social network considering client’s mental illness and, hence, reducing stress and minimising risk of relapse; • help with living: financial support, housing, education, job – negotiate social welfare services

7. ‘Insight in illness’: medicalising and essentialising mental illness • Clients initially were sceptical about taking psychoactive medication – taking medication meant ‘being ill’ • Over time, and due to therapeutic work in service, clients came to accept taking medication and ‘being ill’– focus shifted to a concern with not feeling ill or ‘becoming ill’ (medication as ‘“vitamin pills” to regulate the biochemical balance in the brain’). • The shift from an essential to an experiential understanding of mental illness involved a notion of mental illness as an alien within the self and medication allowed to ‘be myself’

8. Therapeutic processes and the person • Biomedical and ‘cognitive deficit’ notions of mental illness dominated the ‘symbolic healing’ provided in the service (Larsen n.d.b) • These explanations provided the individual with an identity as ‘mentally ill’– and suggested revision of self-perception and life plans (Larsen 2005) • Some clients found these explanations unsatisfying and sought alternative systems of explanation from the wider cultural repertoire in creative work of bricolage (Larsen 2004)

9. The individualisation ofmental illness and health? • The mental illness is individualised – or perhaps ‘sub-individualised’– as agency and individual responsibility is seen as external to the illness that ‘works within’ • Mental health and illness is becoming a question of accessing and applying expert knowledge to manage and control symptoms • Recovery is a continuous process (of controlling and managing) rather than a resolution (becoming ‘healthy’) • In this situation, is individual agency less a question of ‘freedom to act’ than a struggle to obtain and apply expert knowledge to seek to moderate and manage systems and processes ultimately beyond our control?

10. Towards a critical social science of mental health and treatment • Critically investigate the sociocultural processes involved in therapeutic work: • what is it that makes them therapeutically effective? • how are new social roles, identities and self-perceptions created? • How do individuals (patients/clients) experience and respond to and challenge these interventions? • How does the therapeutic ideology and practice relate to wider societal processes such as the market-driven pharmaceutical industry; funding arrangements for mental health treatment; training and practice development in mental health practice; notions of the person and the ‘well-functioning’ individual

11. References Barrett, Robert J. (1996) The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropological Study of Person and Illness, London: Cambridge University Press. Furedi, Frank (2004) Therapy culture: cultivating vulnerability in an uncertain age. London and New York: Routledge. Larsen, John Aggergaard (2002) Experiences with early intervention in schizophrenia: An ethnographic study of assertive community treatment in Denmark, PhD thesis, Department of Sociological Studies, University of Sheffield. Larsen, John Aggergaard (2003) ‘Identiteten: Dialog om forandring’ [Identity: Dialogue on change], In K. Hastrup (ed.) Ind i verden: En grundbog i antropologisk metode, pp. 247-271. Copenhagen: Hans Reitzels Forlag. Larsen, John Aggergaard (2004) ‘Finding meaning in first episode psychosis: Experience, agency, and the cultural repertoire’, Medical Anthropology Quarterly 18(4): 447-471. web link Larsen, John Aggergaard (2005) ‘Becoming mentally ill: Existential crisis and the social negotiation of identity’, In V. Steffen, R. Jenkins, and H. Jessen (eds.) Managing uncertainty: Ethnographic studies of illness, risk and the struggle for control, pp. 197-223. Copenhagen: Museum Tusculanum Press. web link Larsen, John Aggergaard (n.d.a) Understanding a complex intervention: person-centred ethnography in early psychosis, unpublished manuscript. Larsen, John Aggergaard (n.d.b) Symbolic healing of early psychosis: psychoeducation and sociocultural processes of recovery, unpublished manuscript. Luhrmann, Tanya M. (2000) Of Two Minds: The Growing Disorder in American Psychiatry, New York: Alfred A. Knopf. Sharkey, Siobhan and John Aggergaard Larsen (2005)‘Ethnographic exploration: Participation and meaning in everyday life’, In I. Holloway (ed.) Qualitative Research in Health Care, pp. 168-190. Maidenhead: Open University Press.