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

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Presentation on theme: "How Do We Understand Mental Health? In search of an integrating conceptual framework Jerry Tew, School of Social Policy."— Presentation transcript:

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?



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 deconstructA 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 1. Symptoms of an underlying illness 2. 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. 3. 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 dynamics and 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) Genetic riskFamily dynamics Diagnosed with schizophrenia in later life (%) LowHealthy0 HighHealthy1.5 LowDysfunctional5 HighDysfunctional13

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 peoples 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 peoples 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 – Roy Porter

27 The Triple Whammy 1. The experience of mental distress (which may connect with experiences of discrimination and abuse) 2. Stigmatising responses from friends, family, professionals and society at large 3. 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 Vulnerabilit y 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)


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

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