One of the issues that frequently come up in these pages, and in other places where institutional approaches to ‘mental health difficulties’ are discussed, is the discrimination (or stigmatisation) suffered by people identified as ‘mentally unsound’. Beyond individual accounts there are heaps of formal research data that point to damaging effects upon family life and access to housing, and upon friendships, intimate relationships and attitudes to childcare. There is continuing discrimination in the workplace and in healthcare settings. Media portrayals remain obdurately stigmatising, and in some jurisdictions people with ‘mental illness’ continue to experience formal restrictions on jury service, voting rights, holding public office, travel or holding a driving licence. For many, these consequences of being identified as someone with a mental health diagnosis are far more damaging than the experiences that led to such a ‘diagnosis’ in the first place.
Not only is all of this far more than just a little problem for those directly involved, it is a conundrum to those attempting to understand what is going on and do something about it. During the early years of this century the British Royal College of Psychiatrists energetically promoted an ‘illness like any other’ approach, in a well-meaning attempt to ‘Defeat Depression’. Effectively it backfired. Public attitudes towards people with mental illness in England and Scotland actually became less positive during that period, and other formal research has confirmed that similar attempts to defuse concern about mental health difficulties by identifying them as medical problems to be ‘treated’ have had similarly unhelpful effects. The so-called medical model brings with it assumptions of incapacity or incompetence, paternalism and expectations of compliance with ‘treatment’. All of these can be socially damaging. As many who contribute to, and who follow these pages often emphasise, it is not disturbed or disturbing mental states that are the main problem, but how they are understood and responded to by others.
In June 1990, the Los Angeles Times reported on a conference that had taken place a couple of months earlier in Worcester MA, in an attempt to answer the question, ‘What is Schizophrenia?’. Apparently the first speaker offered to list the established facts, and then projected an empty slide. Wry laughter rippled through the assembled experts. These included Manfred Bleuler, son of Eugene Bleuler who had coined the term in 1908, and some twenty other acknowledged experts; prominent psychiatrists, leading psychologists, renowned social scientists, anthropologists, philosophers and historians.
There was no consensus, other than to agree that the phenomenon ‘Schizophrenia’ resists a clear definition. The exchanges uncovered multiple, often conflicting uses of the term. For some of those present at the conference, it seemed to refer to certain kinds of people, for some, to certain kinds of behaviours, for others, to the consequences of certain biochemical events, and for some, to comprehensible psychological strategies. A notable strength of the colloquium was that participants were able to contribute from these differing perspectives in an atmosphere of mutual respect and curiosity. As a result, their collective answer to ‘What is Schizophrenia?’ had to be “We don’t know”.
There were many opinions but these reflected differing positions, research traditions, world views and, significantly, differing approaches to more fundamental questions such as, ‘What is knowledge?’, or ‘Are certain forms of knowledge more privileged than others?’ Answers to questions such as ‘What is Schizophrenia (or any other form of ‘mental illness’)?’, ‘What do we know about Schizophrenia (or any other form of ‘mental illness’?)’, or ‘What is the best way to respond when someone experiences mental health difficulties?’ depend more upon who is asking or answering them, why they are asking, and where and how the knowledge in question was generated, than it does upon the accuracy or validity of what is put forward.
This matters a lot. An acutely distressed person might generate a range of responses: “They are obviously having a hard time and deserve a little more care and attention”, “That person could be dangerous and should be put away.”, “This is nothing a few weeks in hospital on an anti-psychotic can’t sort out.”, “This is the clinical pathway we follow under such circumstances.”, or they might react with “Help!” or “Leave me alone, there is nothing wrong with me.”. Each of these reflects how psychological distress is understood by those encountering or experiencing it, and as the 1990 ‘What is Schizophrenia?’ conference illustrated, what that might be depends heavily upon who you are and where you are coming from.
This goes for formal research as much as it does for less institutionalised ‘knowledge’. Investigators tend to publish and communicate within their own sub-field; neurobiology, psycho-pharmacology, cognitive science, social psychology, sociology, and so on. This is not peculiar to the study of mental health difficulties. It is a feature of systematic, formal research across all fields of enquiry, and it reflects the fact that the growth of ‘knowledge’ is collective, slow and incremental. An investigation builds upon its predecessors. One experiment, survey or review will establish some facts and reveal new uncertainties. These are then, in their turn, addressed by a further investigation. Truly new knowledge only emerges by carefully looking again at what has already been agreed, and how those interpretations might be criticised and reworked. Every doctoral student discovers this, and, equally, discovers that their success is going to depend upon becoming deeply immersed in the details of what is already agreed within their chosen, narrow, self-contained field of study.
Inevitably this process generates and maintains communities of narrow specialism focused upon this, that, or another area of knowledge which are relatively isolated from one another. Individual participants might be aware of, and may even respect others’ fields of interest, but the business of conducting genuine, cutting-edge research is inescapably carried out by relatively small, tightly focused communities of interest which exclude most people who are not, and cannot be, party to the necessary level of detail. This is of little concern in esoteric areas such as theoretical physics, astronomy or archaeology, where findings and opinions have limited impact upon everyday life. In contrast, medicine, psychology, climate science, economics, and engineering, for instance, all have direct effects upon the lives of those who are not necessarily fluent with their fine details.
For most people, what they ‘know’ about this, that or another aspect of these and similar enterprises is a simplified digest of what they believe the most knowledgeable are currently considering. As such it tends to overlook underpinning uncertainties and the nuances of debate among the cognoscenti who are attempting to resolve them. Rather being either ‘right’ or ‘wrong’, what we encounter in everyday life is an economy of opinions in which different views are expressed and traded, differentially valued and differentially respected. What emerges in any one context is the outcome of interactions between people sharing or contesting one another’s views (what is known in the trade as symbolic interaction).
In relation to mental health difficulties this offers an understanding of why any one distressed or disturbing person might evoke a range of differing responses, depending upon the community they live in, the attention they have attracted, perceptions of their background and so on. Clearly, this influences whether they are regarded as ‘ill’ or as distressed, whether they might be considered dangerous, incapable, threatening and so on. It also offers a way of unpicking another major conundrum facing the mental health research community.
For years, at least since the Chicago studies of the 1930s, mental health difficulties have been known to have a social geography. That is to say, the risk of being hospitalised, of acquiring a mental illness ‘diagnosis’, of being treated without consent or suffering other consequences of ‘mental disorder’ are all associated with socio-demographic variables such as racial background, migration status, neighbourhood of residence or ‘social class’. In recent years this has hardened up, as information technology and population data have converged to allow larger and more convincing studies.
The result is a set of findings which have yet to find a satisfactory explanation. Family background, ethnicity, migration status, city life and challenging living conditions are all robustly associated with the risk of being troubled by ‘psychotic’ experiences, as too are adversities in childhood and significant life events. This epidemiology of mental disorder has benefitted from considerable research funding, fuelled numerous academic careers, and populated a great number of research publications and conferences. It is an established feature of mainstream mental health research, and yet it still has little impact upon mainstream mental health services. Recent decades have seen general acknowledgement of a relationship between abuse in childhood and adult ‘mental health difficulties’, with welcome attention to safeguarding and prevention.
There are many voices articulating the need for politicians and others with influence to act against growing levels of material inequality, but these tend to fall on deaf ears. Although there is now a mountain of largely undisputed data identifying relationships between social circumstances and psychological well-being, it has yet to find widely applied traction in terms of policy and service provision … again, a frustration commonly expressed in these pages and similar commentary.
Might this be because we are barking up the wrong tree? Where it is considered, the social geography of mental disorder tends to be seen in terms of ‘Stress’ or of ‘Social Isolation’; that these vicissitudes in some way lead to mental health difficulties. Stress, social isolation and other hardships undoubtedly cause distress, but another widely voiced concern about mainstream mental health services is that distress, per se, is not necessarily an illness, with all the consequences and paraphernalia that implies.
As it is well rehearsed, the consequences of being identified as someone with a ‘mental illness’ are commonly as disabling, if not more so, than the difficulties that led to that in the first place. Perhaps we should be looking more closely at how, where and why that labelling happens. There is nothing new here … Thomas Scheff, for one, has been banging on about it since the 1960s, but the more recent emergence of a widely acknowledged social geography of mental disorder demanding explanations in recent years introduces a further stimulus to this perspective.
Socio-demographics reflect where and with whom people spend their time, who they feel comfortable with, and can trust, and who they might feel uncomfortable with and may not trust. People’s interactions with one another are patterned. They live in a particular neighbourhood, they do or do not go to work and associate with others in a relatively predictable way. Mostly they live with one another, they belong to clubs, go to church, mosque, temple or synagogue, socialise and so forth. Their respect for authority and established institutions varies in fairly predictable ways.
If we accept (as symbolic interactionists do) that individuals’ understandings of the world, including what it means to be experiencing psychological distress or exhibiting disturbing behaviour, is the outcome of their interactions with others, good or bad, then there is scope to suggest a connection. Put simply, socio-demographic variables imply particular patterns of human interaction, and how ‘mental health difficulties’ are understood will reflect those interactions, and is likely to differ, subtly, from context to context in ways that reflect those patterns of interaction. This is a testable hypothesis which could generate productive research focused upon how individual understandings of psychological distress differ from place to place, and how they are generated and maintained.
It is tempting to suggest that the pharmaceutical industry and others that feed off their profits have been on to this for some time, but they exploit it as marketing rather than open, constructive research. They, after all, have a transparent interest in encouraging medicalisation even though there is a lot of evidence that in the long term this is unhelpful.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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