On MIA Radio this week, MIA’s Tim Beck interviewed Dr. Felicity Thomas and Dr. Richard Byng. Dr. Thomas is a Senior Research Fellow in the Medical School and a Senior Research Fellow on the Cultural Contexts of Health in the College of Humanities at the University of Exeter. She is also a co-director (with Professor Mark Jackson) of the WHO Collaborating Centre on Culture and Health and works closely with the WHO Regional Office for Europe project on the Cultural Contexts of Health.
Dr. Byng is a professor in primary care research at the University of Plymouth. Dr. Byng is also trained as a general practitioner with a particular interest in mental health care. Over the last 20 years, he has worked on various large-scale research projects related to access, commissioning, inter-professional working and implementation of evidence-based practice, while publishing extensively on topics related to the social contexts of health and professional care.
Together, Dr. Thomas and Dr. Byng have contributed to the DeSTRESS project, which consists of a team of researchers in the United Kingdom who seek to learn about why and how poverty-related issues have become increasingly pathologized. This includes exploring how high levels of antidepressant prescription and use are impacting people’s health and wellbeing in low-income communities in southwest England.
Their final report published in April 2019, entitled Poverty, Pathology, and Pills, situates increasing rates of mental health diagnosis and psychiatric prescriptions within socioeconomic and policy trends across the UK. An overarching conclusion of this research was that there is a need to reconceptualize the way that health professionals respond to poverty-related distress. This requires a response that recognizes the bio-psycho-social and reduces pressures on general practitioners (GPs) to make rapid decisions around diagnosing and prescribing.
What follows is a transcript of the interview, edited for clarity.
Tim: Welcome both of you. Thank you for joining me today.
Dr. Byng & Dr. Thomas: Thank you very much.
Tim: To get started, can you each talk a little bit about your personal histories and research backgrounds?
Dr. Thomas: I have quite a diverse research background. I started off working in anthropology and geography, but I then moved on to work in international development with a center with an educational background, and now I work in a transdisciplinary center, which is looking at how to create “healthy publics.”
The idea of “healthy publics” being a sort of an inverse of “public health,” which assumes a top-down approach to getting people involved. It’s about creating “healthy publics” from the bottom up. What I’m interested in is social responses to ill-health, disease, and suffering and how social exclusion and injustice can shape health outcomes.
Dr. Byng: I’m a general practitioner and family doctor in the UK. Before that had some experiences working in Africa. Like many academics in primary care, who’ve had similar experiences that tend to broaden our perspectives, I started my practice very much with the idea that we’ve got to sort out the diagnosis and treatment of depression.
Twenty years ago, it was part of the “Defeat Depression Campaign,” trying to encourage general practitioners (GPs) to diagnose and provide more antidepressant medication. Over the years, I have been involved in redesigning services, setting up new interventions, and evaluating them. But I’ve also stayed very involved in thinking about what it means to practice and provide the kind of one-to-one relationship with individuals within a practice. I have done some conversation and other interactional analysis as part of the research.
Tim: Are there any experiences that either of you had in your respective careers that you can remember — or really in your lives for that matter — that led you to become interested in doing this sort of research that you do now?
Dr. Thomas: I think for me, I did my PhD in sub-Saharan Africa looking at HIV and how people conceptualize HIV in a region that had a 43% HIV prevalence rate but where nobody would talk about HIV — everyone was very much in denial about it. I was trying to understand what was going on by looking at the kinds of narratives that were used to explain what was going on.
Most of the health services in the region were pursuing a very biomedical approach. You know lots of public education campaigns around HIV have not been very effective. I was looking at how people in rural areas of the region actually did understand what was happening to them. I think understanding the way people interpret illness or interpret ill-health, what that means to them, and the role of medications within that is something that I’ve always been interested in.
Dr. Byng: For me, there are so many things that have brought me to the point where we started this project, but they included working as a GP with a special interest in mental health in a team for young people with mental health problems, quite significant mental health problems. I started to realize that the diagnostic system really didn’t work for this group. We were dealing with people with very distinct and problematic social problems alongside distressing symptoms.
Then, at the time when Felicity approached me, I was working in a practice, and I was seeing the multiple loads of psychotropic medications that individuals in a very deprived area were taking. I was not just concerned about antidepressants but also opioids, gabapentinoids, and the prescription of antipsychotic medication for people without a psychosis diagnosis. Then alongside that, I’m basically a generalist practitioner and researcher but have become increasingly interested in critical realism, as a way of kind of holding the different views from an ontological perspective.
Tim: Drawing on that a little bit further, can you talk a little bit about the history of the DeSTRESS project and sort of how it got started? How did each of you become affiliated with it?
Dr. Thomas: At the time of the project, I had been working in a different part of the university concerning issues of sustainability in health care. One of the things that I was particularly interested in was the way the huge increase in prescriptions in the past few decades and there didn’t seem to be too many conversations going on at the time about why that was.
There was sort of an implicit assumption that this was a good thing and that it meant that we were addressing health challenges rather than taking a more critical perspective and saying, well, why might this be? Or what’s going on on the ground in a cultural and social sense, and also in a policy sense? What are the agendas driving this increase in medicine use?
I was also working in a couple of very low-income communities in the UK, where I was seeing everyday stresses and the hardship that people were facing but also the very high use of antidepressant medications in those communities.
We’ve also seen in the past few years in the UK a big government drive to support mental health, which is great as part of a drive to de-stigmatize mental health issues and to increase treatment availability to people who need it. On the surface, that all sounds very admirable. However, what I was seeing in the communities I was working within is that this was taking place within the context of very harsh welfare reforms. We’ve had a long period of austerity in this country. There’s been a lot of welfare reforms, which are really quite punitive and many people were really suffering as a result of that.
I was trying to look at how those two things kind of came together. On the one hand, we have a government that says they are supporting mental health. On the other hand, in very low-income communities, what we’re seeing is that actually, people are experiencing more and more distress because of the hardships of poverty, created by a government agenda. How do mental health agendas and the welfare agendas match up? How do they come together, and what does that actually mean for people’s lives on the ground?
Dr. Byng: Well, for me, it was being approached by Felicity. I had conversations with people indicating my interest in the problems of living within a resource-poor community and prescriptions. We got together, Felicity came and sat in on my practice, we talked, and she went away and wrote a beautiful proposal. I thought, well, I can’t say no to being involved in this.
Tim: It seems like the DeSTRESS project focuses on issues that have traditionally been marginalized within healthcare communities. Would you say that’s true?
Dr. Byng: Yeah, I think there’s very little work that is bringing together the discourse within consultations and the discourses that are going on within the community around mental health, and trying to examine these from a general practice perspective. Within the UK, because general practitioners and family doctors are the first points of call for many people with mental health problems, these issues are particularly pertinent, but it has been understudied.
Dr. Thomas: In addition to these issues being understudied, I think it is also about trying to understand what’s going on from the perspectives of people in low-income communities. It is certainly a community of people that tend to be quite neglected in health care research generally, and particularly in mental health research, In the UK, so much of the literature around mental health care is based on what goes on within the consultation rather than actually trying to step back and see the broader context of people’s lives.
Tim: Given the way that these issues have traditionally been marginalized within healthcare communities and specifically in psychiatry, it seems that you’re approaching this from a more critical perspective than you would typically see in mainstream research. I’m curious if either of you identifies yourself with the critical psychiatry movement, or are there any other theoretical traditions or social movements that either of you would identify with?
Dr. Thomas: I think it wasn’t something that I specifically set out to identify with. My interests were primarily in health inequalities, and I was less familiar with a lot of the psychiatry and anti-psychiatry movements at that stage. However, I guess, yes, I would say that there are certainly parallels now in what we have found, in that the research raises a lot of concerns about the ways that diagnostic categories are being used, as well as concerns about the evidence around the effectiveness of treatments that are offered in relation to poverty-related distress.
Of course, one of the things that we’ve found in the research is the length of time people are on medications. Within low-income communities, people tend to be left on antidepressants, or they stay on antidepressants for a very long time. One of the concerns we have is what that really means. We don’t actually know very much about the long-term implications of using these medications for many years on end.
Dr. Byng: Looking broadly at the critical psychiatry movement, I had considered myself to be on the edge of it, not an active participant, but very much concerned with the diagnostic system and the levels of antidepressant prescribing, and other medications, considering the relative lack of effectiveness of those medications.
Also, I’m very keen on ensuring that we have a really strong evidence base to understanding and critiquing these, and use a whole range of traditions. I find the sociological approaches really important, as well as political and psychological approaches. I’m not completely opposed to a deficit-based psychological model being incorporated into a critique, and I have used a kind of critical realism as an overarching philosophy of science and social science to bring together those ideas.
I think, at one level, something that is not always pushed by the critical psychiatry movement is an understanding of the neuroscience. I think that the amazing plexus of neurons that is our brain is the kind of key to understanding this. Firstly, I think we do have tendencies that are genetically driven, and I think we need to own up to those. But most importantly, I think that the environment in which we live (the social situation, our past traumas) all influence how our brains work in a very profound way.
For me, a critical realist approach helps bring those together and look at those causal links. For this project, seeing how both past traumas and events and the deficits within opportunities, positive opportunities, positive experiences in resource-poor areas, and the excess of a negative influences — be it violence, interpersonal issues or the humiliation of having to go through various social care systems — will profoundly influence how the brain works and contribute to distress.
Tim: Given that there does seem to be such a strong empirical base for the relationship between poverty-related issues and mental health suffering and distress, why do you think that these broader socioeconomic issues have been traditionally marginalized within psychiatry specifically, but also within healthcare communities more broadly?
Dr. Byng: Well, I think that the social sides have been recognized within psychiatry. Within the UK, there’s a strong tradition of social psychiatry and interventions supporting the social sides have been in place for a while.
I think the problem is more of just a disconnect between a desire to have a tradition of medicine that’s evidence-based, that’s based on diseases (so there are things that need fixing), that doesn’t fit well with an account where distress is actually to a large extent originating from social issues. I think it’s more that there’s a disconnect and there isn’t an overarching way of bringing them together, politically and amongst professional bodies.
Dr. Thomas: I want to add one of the things we found when we ran some of the findings past trained [general practitioners (GPs)] in the UK. We ran two workshops to talk about our findings and to involve some of our community partners, speaking to their experiences of talking about mental health with the doctors. We found quite a difference in the way that the information we were getting was received by people who are being trained [currently] as GPs compared to those who were much more experienced GPs.
I think there’s an issue there around the way that people receive training on mental health in the UK because some of the messages that we are trying to convey didn’t sit very comfortably with some of the NICE (National Institute for Health and Care Excellence) guidelines around mental health and what GP trainers should be doing. The more experienced GPs completely understood what we were saying because they have to live and breathe this every day.
The other thing that I wanted to mention is that, at the moment, we do have a government who seems to be very much in denial around the things that they don’t like to hear. We had a UN report on poverty in the UK. It was released, and there was a huge number of submissions to the UN Rapporteur who was putting this report together from organizations across the country on poverty and the impact it was having on people’s lives. The government’s response to this was to deny all of the findings of that report.
Similarly, with the DeSTRESS projects, we had a BBC report go out a couple of weeks ago, and the reporter got some political commentary on that as well, and the government response was there was no evidence that poverty has been over-medicalized.
It’s very much a kind of non-listening government at the moment. They don’t want to hear things that don’t prop up their policies or don’t prop up what it is that they’re trying to put across. There’s something not quite working there. It’s hard to get people to listen sometimes to things that don’t say what they want to hear.
Dr. Byng: And I think there was a particular concern about any suggestion that the model of needing to fix people’s brains through the use of antidepressants was problematic. There was a kind of reluctance to see that there may be inappropriate prescribing, that some people might not benefit from medication. Whereas I think many of your listeners will recognize that medication might work only for a few people and not necessarily for the reasons that are based on the original constructs that are being put across around neurotransmitter changes.
So, there’s a real disconnect there with a failure to see that some of the solutions might lie in changing the social circumstances. Alongside that, you’ve got the kind of neo-liberal tradition that comes in that says, “actually people need to sort themselves out.”
It’s interesting because it’s not a long way from a position of saying, let’s help people use their strengths and support people in their very difficult lives. But the current paradigm has this split that’s, on the one hand, sort yourself out and, on the other, you’ve got a disorder, you need a diagnosis and medication. There is a failure to bring those together.
Tim: I noticed throughout the report that the concept of narrative figures heavily into both the way that you organize the research procedures and also how you talked about the results afterward. What does the idea of narrative offer in terms of doing the sort of critical research on mental health care systems that your project focuses on?
Dr. Thomas: I think for us the whole reason for using narratives is so that we could understand why people were experiencing what they’re experiencing. It was about trying to understand why particular health care responses were being framed in particular ways.
With the DeSTRESS Project, we were concerned with looking at what these dominant narratives were and, on the one hand, we have a government narrative around the need to improve people’s mental health, and the need to improve access to treatment, which in this country means antidepressants or talking therapies. Then, at the same time, we have narratives around poverty and why people are in poverty, and these are generally narratives of shaming and blaming people.
So, rather than just accepting the biomedical narrative that is very often used without question in mental health research, we wanted to critique it a little bit more, start to pick it apart, seeing why these narratives were being put together, and how mental health narratives connected with the narratives around poverty. We wanted to think about whether these narratives were coming from, who was driving those narratives.
The thing with narratives is to ask why is that story or that narrative being told in that particular way? What kind of agenda does it serve to push narratives in that way? Because there are other ways of telling the same story. I think one of the things we’ve tried to do is to bring in people’s lived experience and tell the story from the perspectives of people who are living in poverty, around their experiences of distress or mental health issues, depending on how they themselves frame issues.
Dr. Byng: I think what has been really fascinating is listening to individuals in the community, in resource-poor communities, and general practitioners in those situations. What we’ve done is interpret their perception of these narratives that are going on within the media and government and policy. Seeing the utter confusion of both sets of stakeholders, we found that individuals going to receive care are experiencing the sense that they should get care in order to be responsible people, especially if they’ve got children. Then, perhaps at the next encounter, they can be told that there’s nothing that can be done, that they need to sort out various things themselves.
There is real confusion. There is the potential for both the shame narrative, of not doing it right — which fits with the idea that you should get on and sort yourself out. But also the shame narrative can be such that you can be shamed into receiving treatments. You’re encouraged to get treatment when you might not want any treatment, or you might not want the medication that’s offered. It’s just been fascinating trying to access individuals’ responses to those dominant policies and professional narratives.
Tim: Going back to the focus of the research of the DeSTRESS project, it is talked about on the website as being an interdisciplinary endeavor that uses a mixed-methods research design. What would you say it is about the nature of these issues, poverty-related social problems, that warrants such an eclectic approach to doing research?
Dr. Thomas: I think it’s really necessary for all research to try to work in an interdisciplinary way because I think you gain so much in doing so. I think for this particular project, we thought it was necessary to understand different perspectives and experiences and to gain insights into people’s lived experience by approaching the topic through our different disciplines.
I think that being able to talk together about what we were seeing and to analyze what we were finding from those different disciplinary perspectives opened up conversations that we probably wouldn’t have had from a single discipline project. It’s been really important for us to be able to disseminate the findings to different audiences in a way, again, that we wouldn’t have been able to do if we were just coming from one discipline. Certainly for me, I’ve learned an awful lot during the project about how to relay information effectively to health professionals.
I’ve realized that it’s a very different kind of language and a very different way of disseminating information than I have done, and am used to doing, in the social sciences. Also, we had psychologists who were using conversation analysis, looking at video recorded conversations between GPs and patients, and trying to look at understanding those interactions and how interactions influence the course of that consultation, the likelihood or not of somebody taking treatment, and so on.
There are things that have been so insightful in this project. It is like pieces of a jigsaw. By having one of those different perspectives and all those different insights, we’ve been able to piece together something which we really would not have been able to do otherwise.
Tim: I also notice that in the report it talks about taking an engaged approach to research. Could you say a little bit more about what you mean in the report about taking that engaged approach?
Dr. Thomas: Rather than it just being an academic study, which is lead only by academics, an engaged approach means researchers and people outside of the university actually work together in a meaningful way. Not just at the end of the project, or at intermittent periods, but throughout the research process; to try and understand the nature of the issues that are being researched, to try to co-create some of the core questions that we’re asking of people, and to analyze the data.
It has been fascinating to take some of our data back to people in low-income communities and get their perspectives on what they see in that data because very often, it was quite different from our interpretation. It’s also about people outside of the university being involved in delivering and disseminating the research findings. Finding out who they want to disseminate the findings to and how they want to do that, and what’s going to be effective for them.
Overall it’s about working together in partnership to ensure that everybody benefits from the outcomes of the project, rather than it just being an academic exercise where academics get to read the findings in a language that is not accessible beyond academia. It’s about making the research potentially beneficial to everybody, particularly those people who may ultimately be affected by the research’s findings.
Dr. Byng: To me, the main change that results in the work we were doing being engaged is having individuals from communities as parts of the decision making. They were absolutely adamant that maybe we could do something around supporting GPs to behave differently, and that was absolutely what they wanted to happen.
In terms of our dissemination, while we’ve been able to do the high-quality social science analysis, we have also said, okay, we will work on producing a package for GPs to think about how to operate in this really difficult area, and to support GPs to provide better care. And that came from the communities, that’s what they wanted. I think that’s been really exciting to be able to add that as one of the key outputs.
Dr. Thomas: We’ve tried to involve our community partners in a number of dissemination events and conferences that we’ve been involved in, and every time we’ve done this, when we’ve done an evaluation afterward of people in the audience, the thing that people find most powerful and most memorable is the community involvement. The community members are able to convey messages in a way that makes a much more powerful impact on people.
Tim: On the other hand, then, it also seems like there’s a certain sense in which mental disorders represent experiences that are inherently beyond our normal interpretations of norms about human behavior and in fact they often trouble our taken for granted understandings of the world. Would you say that there are any limitations to using the concept of narrative as a guiding frame for research such as yours?
Dr. Thomas: I think what some people see as a limitation of narrative approaches is that they do not provide facts; they do not provide the truth. But that is not what we are pretending to do. What the narrative approach is doing is trying to seek understanding rather than truth. It’s about understanding how people make sense of what’s happening to them. So for me, I didn’t see that as a limitation, but some other people do.
Dr. Byng: I think the narratives form an important part of lots of types of research where you’re looking at social phenomena and how things are experienced. It’s also really important to look at things from different perspectives. I see narratives as one of several ways of looking at things. Pretty helpful.
Tim: I guess maybe another way of framing the question is, do you think it’s possible for narratives such as the ones that you’re studying and revealing in the discourse to be appropriated by the same systems that you’re working to expose in the research?
Dr. Byng: I think there’s plenty of examples of how narratives can get twisted and turned in. We could say that the recovery movement in mental health in the UK, people argue it’s been expropriated. I think we’re aware of this tension between the medicalization narrative, with fix it, and you’re broken, you need to be sorted out, go and get treatment, that’s the right thing to do versus the opposite one.
One of the things that we’ve been focusing on, particularly in the support to practitioners, is trying to create a way of working that bridge those two narratives. So that we don’t go down the line of saying, “medication doesn’t work, so this is something that you shouldn’t do at all,” which could easily happen. “As practitioners, that’s just not your business. Distress is no longer on the agenda for GPs to manage.” That’s certainly not what we’re saying. So trying to bridge that is tricky.
Tim: I’m curious about the three categories of narratives that you parsed out in your final report. You described them as neoliberal narratives, shame narratives, and medicalization narratives. You talked about these as separate categories, but you don’t seem to talk about how they’re interlinked and how they show up in complex ways. So could you unpack these three a little bit for me and talk a little bit about how you see them as being interlinked?
Dr. Thomas: Okay, Richard, you can step in because you are quite good at describing these narratives. I think we have a neoliberal narrative where others see people with distress as having some kind of social-behavioral problem that they need to get fixed, that they need to get sorted out for themselves, in order to be seen as being responsible citizens.
What we’ve found in the research is that people very often feel quite guilty about it. It is a kind of narrative that makes people feel bad about themselves but also quite helpless in terms of knowing how to respond. Because if you’re living in poverty and there’s not much you can do to kind of get out of that situation, and you’re constantly being told that it’s your fault. It’s a very damaging narrative unless people are actually given the resources to be able to help themselves.
We also have a shame narrative, where people who are not considered to be contributing to society are somehow seen as being reckless or irresponsible. That’s the kind of narrative that we’ve seen very much in political rhetoric and the tabloid media in this country. It’s very much a shaming, blaming narrative where people who are living in poverty, particularly people who are reliant on welfare, are seen as a problem. And they’re seen as “scroungers,” which is one of the words that’s been used.
What we see here is that people feel like they’re being judged, and then they avoid seeking help. They feel that if they go to get help, then they’re going to be judged for what other people see as reckless behavior. We found that in many instances people, particularly people with young children, actually, took themselves out of the system.
They didn’t seek help anymore because seeking help was more stressful and the structures that were originally put in place to support people were actually viewing people through a lens of risk, and not helping people as a result.
Then we have the medicalization narrative, which Richard has already talked about, in which mental distress is just seen as a medical issue that requires medical intervention. We found a number of GPs talking about mental health issues through a medicalization narrative, but then also GPs talking about poverty-related distress as a social issue.
One of the interesting things we found is that even where GPs saw mental distress as a social issue, they still ended up medicalizing peoples’ problems because there are very few other options available to GPs. It was very difficult for them to be able to offer any other kind of response.
Dr. Byng: I mean, I go back to the idea that actually people are feeling conflicted by dominant narratives that don’t always fit easily with each other. In one moment, an individual with children will avoid help because they’re scared of having their children taken away, for not being seen as good enough parents. Then, in the next moment, in order to get benefits to support their children, they would need to have a diagnosis, and they go to the job center and make that pretty clear.
Then they might need to be seen to be going to the doctor to get antidepressants and that it would be the right thing to do to get treatment in order to help their children. Then they get referred to a service who says, “well, you’re not good enough,” or “you’re not ill enough, so you’re not suitable, and you’re not a candidate for this kind of treatment, so you have to deal with this on your own.” There’s a lot of conflicting narratives that I think are very confusing and bewildering for people.
Tim: It seems like this idea of risk assessment or identifying and assessing risk and then intervening on risk at the social level seems to be pretty pervasive across these narratives. It also seems like a major focal point of the study was how policymakers use these narratives to control public discourse about mental health. Could either of you speak a little bit about how you see this as being related to maybe the privatization and capitalization of mental health and mental health care or healthcare more generally?
Dr. Byng: I’m not convinced that this is the main issue. I have to say that within the UK, we have mental health services that are state funded through taxation. And while some services operate outside of the NHS that are paid for by the NHS, and there is a market system in the sense that those services are commissioned, I think that these problems are operating within what is effectively a social care provision.
The NHS is effectively a residual socialist innovation, and they’re still operating within that, 50 years on since the NHS formed. I think you’ve got a neoliberal overlay of essentially the professional based idea that you can fix people. You’ve got these two problems that are operating together. We don’t have the same issues of capitalization that you have in the US. So I think things can happen within a state system.
Dr. Thomas: I think Richard has put that beautifully, to be honest. I mean, I think the only thing I would add to that is that one area where we did see a lot of discontent amongst people in low-income communities was when they were being reassessed for benefits, for welfare benefits. They were having to go along for what, in the U.K., is called a “work capability assessment,” where their fitness for work is reassessed. In the UK that is increasingly done through private companies.
That did cause a lot of angst amongst people who were having to go outside of their comfort zone often to a town or a city that they weren’t very familiar with to be assessed by somebody they didn’t know. In a situation where their GPs make the decision, and their GPs give the expert advice, they could actually be overruled by a complete stranger they’ve never met before. That’s really the only thing I wanted to add to what Richard said, but I agree with Richard that the issues around privatization and capitalization of mental health are not really the core issues that we’ve been concerned with because this is not so much an issue in the UK.
Tim: Yeah, that seems like an important point to make, that these neoliberal narratives can often be overlaid on top of public discourse, governments, and other essential public services and not just private services. For me, that’s also closely related to another point that you bring up in the final report. You talk about one of the main problems with these narratives is the way that they focus at the level of the individual, and they propose interventions at the level of the individual. Could you talk a little bit about this and maybe say whether or not you see this, maybe, as primarily a conceptual issue or an ethical issue or somehow both?
Dr. Thomas: I’d say it’s probably a bit of both. I mean, I think in the context of the DeSTRESS study, which was specifically concerned with low-income communities, and poverty-related distress, it is absolutely vital to take on the wider contextual and social-societal issues rather than placing the blame, or placing the focus, just at the individual level.
In these communities, if you focus on the individual level, it’s reiterating blame for people’s behavior. I mean, that’s certainly just the way it’s being played out here, that’s the kind of narrative that’s being spun here. It fuels the stereotype around individuals as being reckless and irresponsible, rather than actually looking at that much wider context around what is causing these poverty-related issues in the first place.
Dr. Byng: I see that both are really important. Within any new model that we want to be putting forward, we have to understand the local context — the culture, the structural problems, in terms of oppression and power, but also the difficult relationship issues within cultures and subcultures.
We were aware that within poor communities, we’re not just dealing with the oppression occurring externally through austerity, but also individuals are concerned with violence, and particularly violence to women and children. That needs to be looked at along with difficult relationships. I think taking the whole community’s perspective is important, but I also think that understanding things at an individual level is really critical.
I think the message is wrong of having a purely pathology based idea that there’s a disorder and that needs fixing by professionals. Instead, we need a highly individualized understanding of each person. Now that doesn’t need to necessarily mean that each individual needs to gain help from healthcare providers — quite the opposite. I think we need to be moving towards an understanding of mental well-being and distress that’s integrated.
We can look at our strengths and our weaknesses and our experiences, understand ourselves in our social context at the moment and see how that affects how we feel. We can also recognize our strengths so that we can see where we have agency and connect to change things and not just to expect it to be fixed either by benefits or by medication.
It does lead to a kind of communitarian type perspective or some of the third way perspectives that never really developed a proper theoretical approach. For me, it is a both-and, we need to have the individual perspective, but it’s about supporting the individual to use their incredible strengths, imagination, and abilities in order so that they feel better and can participate better. At the same time, we have to abolish the structural inequalities that, unless they are abolished, will continue to create an “unequal distribution of context.”
What I mean by that is that there’s an unequal distribution of things that support people’s mental health. You know, opportunities for jobs, peaceful environments, recreational spaces, and there’s an unequal distribution of things that cause mental health problems, such as interpersonal violence, trauma, humiliation going through benefits systems, and work which is shaming, etc.
For me, it’s a both-and situation. If you want, I could talk a bit about how that needs to play out in the consultations and what practitioners need to need to think about and what services need to be set up within these communities.
Tim: Yeah, that was going to be my next question, because the study seems to indicate a general over-reliance on general practitioners in treating mental health issues. I was wondering if you could, Dr. Byng, talk a little bit more about what you see as being the implications of the narratives that you uncovered in your research for how general practitioners might approach mental health.
Dr. Byng: Yeah. Essentially we have to find a middle path so that practitioners can understand individuals in distress and individuals can understand themselves, not as having a pathology that needs fixing, but in need of support that can make, possibly, a small difference.
I want us to develop a package of an intervention for supporting practitioners to work with individuals that helps them understand themselves as bio-psycho-social wholes. So, “what is it that in the past has made a difference positively or negatively? What’s going on now that is causing distress? How do you understand different aspects of distress?”
“Psychopathologies” is not a very popular word in critical psychiatry, but understanding the different types of distress is important. Is it rumination and overthinking things? Is it mood going up and down in a way that feels uncontrollable? Is it perceptions such as hearing things when there’s no one there, or seeing things, or flashbacks? I think we have to help people to see these as the natural and normal responses to trauma and difficult situations and to understand at an individual level what is happening. Then support people to think of the responses.
The responses might be social; it may be trying to address the interpersonal things that are going on, trying to get support out of problems of poverty. But it might also be about learning to deal with some of these very difficult internal experiences of mood instability. For practitioners, they need to learn some really difficult skills.
One of the most important things that we learned from the project was how people feel judged by practitioners, and small things can make a difference to make people feel judged but also to make people feel part of the common humanity — encouraging practitioners just to make small changes to how they approach individuals to support, so that they see an individual as a friend, as a fellow member of the community, and as having done something productive.
Recognizing the good things that people are doing, the amazing things that they are already doing to deal with their distress could make a real difference — alongside that recognition, working out whether medication might make a small difference for some people and testing it out. Practitioners need to understand, and this is really difficult for them, that medication won’t work in most people and might not work at all.
Learning to be honest about that evidence base is really critical and sharing that uncertainty, as to whether it might make a small difference (that might be helpful or not), as a part of an overall package is critical. Those are the kinds of things that are really difficult for practitioners to take on board because they are so used to the fixing using the diagnostic model of medicine.
Around that, you need a community approach as well. We need to have a range of opportunities that people can often go straight to, so they don’t always need to come to a GP. They didn’t need a diagnosis of depression to know that they’re sad because they have debt, they need to understand and it to be part of the common narrative that yeah, being in debt is going to make you unhappy. That’s understandable. Let’s set your debt out and go straight to the debt advice, bypassing the general practitioner.
I think that’s what I was getting at it, and you were picking up, in terms of GPs not always being the answer. Many things people can learn about, can reconceptualize their mental distress and wellbeing, then recognize what they need and go straight to it without necessarily needing a GP. But, on the other hand, inevitably we will see many people in distress, and we need to support them in that process of learning different ways of thinking about mental health problems that are both compassionate but also allow them to take some control themselves.
Tim: You’ve both talked about how politics, in a more general sense, plays a role in these processes. Particularly in terms of how the government might propose austerity measures, which then ends up individualizing the problem and creating this deficit-based model. But then I’m curious, on the other side, maybe in a more organic political sense, could one of you speak to what role peer-support groups could play here? Something like the hearing voices network or other peer support groups that exist to provide a sense of solidarity around these sorts of issues?
Dr. Thomas: Yeah, I think we found these types of cases probably are the most effective and meaningful in supporting people in low-income communities. One of the big issues that people are facing who are living in poverty is social isolation. This is partly because people don’t often live in their community anymore.
What we’ve seen in this country is very often people, if they’re in the social housing, they will be moved to different areas of the cities, and they get moved away from their social networks. If you don’t have money to travel, you don’t have time to travel, and you have young children or whatever, relying on public transport can be really problematic. People do feel very socially isolated.
At the same time, in some of the areas where people are living, people are afraid to go out. I mean, they don’t want to go out and spend time outside trying to meet people because they don’t want to leave their homes. We’re often talking about people with young kids, and there is a genuine fear about going out and engaging with other people when you didn’t know people. Social isolation is a massive issue.
People are also constantly feeling judged by other members of the public, including within their own communities. People feel judged in their interactions with service providers. Like I said before, many of these organizations that have been set up to support people, actually some of the rhetoric that gets used when these people are talking to community members is very judgmental, and you only have to have a discussion with people to hear some of that narrative coming out.
We had a number of informal discussions with professionals who would talk about people living in poverty as, “Well, you know, that they chose that lifestyle, that they can’t be bothered to help themselves. I think they like being mentally ill, I think it gives them something to talk about.”
Those kinds of things were said in so many conversations that we had. So there is that. People really feared being judged, but what we found is when people did get involved in peer support groups these groups were enormously helpful to them because they provided a nonjudgmental space for people. They will normally run at times or places in places that suited people. They could get to them, and they can take their children along. People suddenly had very powerful friendship groups. Those who had been able to join those groups have really strong support.
For those people who do feel that they can join those groups, absolutely they’re a lifeline. Of course, what we’re also seeing with austerity is huge resource cuts to supporting community groups. Places for people to meet like public libraries are becoming more and more difficult because like I said, they’re closed down or having their hours cut. People are struggling to get even small amounts of money to run these groups.
For example, craft groups are quite big in areas but just to get a small amount of money to hire a room for an hour and to buy a few basic craft materials, people don’t have that money, and there’s no way to get it. So, it doesn’t take much. But it’s being made more and more difficult for people to actually be able to do that in any kind of long-term sense.
Many of the groups that we did come across were run very sporadically, or for very short periods until they could get a little bit more funding. So, absolutely, these groups are vital to people: they give people a sense of reassurance, a sense of purpose, and a sense of belonging. But governments in the UK, successive governments, are reducing funding for these activities most of the time, making it harder for people to connect.
Dr. Byng: I completely agree that a whole range of support and self-help groups are really important as a part of the suite of support that needs to be available in communities, both signposted from GPs or for people to go direct to, and they can operate in a way that Felicity describes.
I think at this point it’s worth also making sure that we’re not making it seem that these are going to solve all the problems. My view on these things is that, for most people, most initiatives, if they are helpful, they help for a bit. Occasionally you have initiatives that are transformational for individuals. We shouldn’t set people up to have overly high expectations.
There is another kind of interesting phenomena that started to spring up that relates to an older phenomenon on the left. The left has advocated for more services for a long time, and now that is slightly in conflict with the kind of things that we’re saying, that we don’t necessarily need more medical services. But there are people on the left who are arguing we need more and more mental health services including diagnosis and medication, etc. I think we need to be careful and really aware of that and support people to have a more nuanced view.
That is the kind of complex phenomena that are coming up in some areas. I think it was evident last year following the Twitter storm around Johann Hari and the Lancet’s meta-analysis of people saying we deserve our medication, and we want our medication. You know, the proud to be depressed and proud to be on medication type groups that were becoming ever more evident on social media. It’s interesting to be aware of all of the different aspects that can occur.
Tim: Yeah, it strikes me that maybe the main thing is not to overgeneralize all people who are showing up to receive services for any number of problems they might be facing. And also to understand the way that both politicians on the right and the left tend to overgeneralize in their way, either by proposing austerity measures that individualize the problem or maybe over-medicalizing and providing services in ways that might not always be helpful.
Dr. Byng: Absolutely. Yeah.
Tim: I want to thank you both for your time. I know you both busy, and I appreciate you being here, but I want to give you both the opportunity to close up by saying something about how this research might change both of your practices or professions individually in terms of your individual practices. Will it change the way that you approach research in the future or the way that you practice in your general practice?
Dr. Byng: I think it’s already changed how I’m working. I’m absolutely much more concerned to ensure that every individual who I see hopefully comes away feeling that they are a valued human being by making small changes to how I interact with individuals.
From the research point of view, a renewed commitment to engaging with working with individuals and ensuring that they are a really important part of driving the direction of the research.
Finally, I’d like to say I think that if we can bridge these very difficult paradoxes and divides, we can make sense of this. Because there is, you know, no magic bullet for distress. I think it is possible to take a whole system and a set of resources around the community and create a much more positive set of interventions that operate both at a community level and within a consultation level that neither pathologize nor shun people and tell them to sort themselves out.
Dr. Thomas: Yeah, I think to reiterate what Richard is saying about the engaged research approach. I think, for me, I have always tried to involve the people in the research I was doing.
Actually, I think this project really brought home to me how important that was. We were very lucky in being able to have an engaged research approach throughout this research, right from the conceptualization of the issue that we wanted to research, to steering the project, thinking of questions, thinking how we analyze the research, how we disseminate the research. Involving people in that process throughout has been so insightful and so important for us. For me, any research I do in the future will absolutely take a similar approach.
Tim: Excellent. Well, thank you so much. I want to reiterate, again, how much of a pleasure it was talking to you both today and how grateful I am that you took time out of your busy schedules to come and speak to me today.
Dr. Thomas & Dr. Byng: Okay. Thank you, Tim.