A recent article published in the Journal of Mental Health explores the language used to discuss mental health issues in parliamentary debates around the UK’s 2007 Mental Health Act. Psychologists in the UK analyzed these debates using a discourse analysis methodology, highlighting how members of parliament frame or “construct” individuals in the mental healthcare system. These constructions, such as “expert” and “patient,” serve to reinforce existing narratives around, for example, the “risk to public safety” posed by the “mentally ill.”
“Mental distress has not always been described as a disorder or illness. It has been constructed differently throughout the ages, being regarded variously as a visitation or punishment from the gods, demonic possession, ‘madness,’ or ‘lunacy’ or requiring rational inquiry. It was only in 1774 that British legislation on mental disorder first mentioned doctors when the Madhouse Act allowed doctors to visit asylums,” write UK psychologists Tom Kent, Anne Cook, and Ian Marsh.
Theorists of psychology and psychiatry have challenged the idea that mental disorders are rooted in biology and universal across place and time. Scholars from diverse disciplines, such as philosopher Michel Foucault, existential-psychiatrist R.D. Laing, and critical social psychologist Kenneth Gergen, have argued for a social-constructionist approach to ‘mental illness’ that recognizes that the ways in which mental health is conceptualized and talked about in society impact the lived reality of mental distress.
Researchers using the qualitative research methodology of discourse analysis (often inspired by Foucault’s ideas) have aimed to show how psychiatrists and psychologists talk about and frame their discussions of mental health can actively bring into being certain types of people and illness experiences.
According to social constructionists, this is achieved by legitimizing and circulating these framings through avenues such as institutional power and laws. For example, they investigate how the American Psychiatric Association’s DSM-V influences so many mental health practitioners in their understanding and practice of clinical work.
Aside from the psychiatric industry, government legislation is another site where mental illnesses and “subject positions” within psychiatry are constructed. The current study utilizes the qualitative discourse analysis methodology to understand how individuals within the mental health field are constructed in –parliamentary debates around the UK’s 2007 Mental Health Act.
Following research procedures described by critical psychologist Ian Parker, the authors analyzed a 215,500-word transcript of the Public Bill Committee debates surrounding the Mental Health Act.
The authors found two main discursive “constructions” within the debates around the 2007 Mental Health Act: the “expert” and the “patient.”
The “expert” in the debates was framed as someone who is knowledgeable, has received training, and is assumed to be trustworthy. Those involved in the debates often deferred to the expertise of psychiatrists and other mental health professionals, typically describing themselves in contrast as laymen.
This understanding of psychiatric expertise coincided with the belief that whatever professionals say must be definitive about how mental health care is approached. Public officials involved in the debates reinforced psychiatrists’ expertise by citing the “long training” they undergo while also contrasting them with psychologists and nurses.
According to the study’s authors, this construction of expertise can “serve to devalue and obscure other types of expertise and knowledge,” ranging from service users’ own personal experience to the potential expertise among friends, family, or one’s broader community.
“The construction of trustworthiness has the effect of making the questioning of psychiatric practices as unnecessary. Little mention is made of any limits or challenges to medical expertise. The combination of expert knowledge and training and assumed trustworthiness could be seen to have the result of inviting us to accept their authority to make decisions on our behalf.”
The second main construction, the “patient,” was described very differently in the debates. “Patients” were often talked about as “non-compliant” regarding treatment, as being of a potential risk to the public, and as having impaired decision-making.
The effectiveness of medications and the necessity that patients take them was assumed to be self-evident in the debates. This, along with the construction of failure to comply as potentially leading to homicide or suicide, led non-compliance to be framed as highly dangerous.
The authors state that the deterioration of a patient’s mental health was automatically assumed to be the result of non-compliance around medication:
“Unfortunately, parents, carers, and others would often have to stand by and watch as the patient deteriorated to such an extent that they had to go back to the hospital for another detention. That could happen time after time. It often happened because people had failed to take medication and to stay in touch with health care professionals,” stated one member of parliament.
Regarding the potential risk to the public, the authors note that “high profile but unusual historical events” were presented as evidence that some individuals need to be involuntarily detained. For example, these include the case of Michael Stone, who was “convicted for double murder and diagnosed with a severe anti-social personality disorder” in addition to drug and alcohol abuse.
For the authors, this kind of framing or construction of the issue—mental health “patients” as dangerous and in need of detainment—may make the issue worse rather than keep individuals and the public safe.
The third discussed attribute of “patients” was impaired decision-making. About suicidal and parasuicidal behaviors, for example, it was often assumed in the debates that individuals had no agency and that their “illness” necessitated decisions being made for them by professionals. One member of parliament stated:
“Clearly, in a clinician’s professional judgment, if somebody were going to self-harm, that would automatically raise the question of impaired judgment.”
Concluding, the authors point to potential reforms:
“In thinking about future possibilities, Kinderman has argued – regarding the Mental Health Act – that decisions should be based on risk to the self or others rather than whether a person is “mentally ill” or not. He suggests that a human rights approach should be at the heart of these decisions. While not suggesting that enforced treatment and detention should be abolished altogether, it paves the way for the concept of mental illness to be decentered from responses to issues of risk.
Indeed, decentering mental disorder from risk could make it possible to have a debate about risk management in society in totality – where the risks in mental disorder are considered in relation to other societal health risks and harms (e.g., unprotected sex, binge drinking, smoking) that do not have the same levels of restriction.”
Kent, T., Cooke, A., & Marsh, I. (2020). “The expert and the patient”: A discourse analysis of the house of commons’ debates regarding the 2007 Mental Health Act. Journal of Mental Health, 1-6. (Link)