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 meaningAffirmative relationships, identities and statusesConnectedness: ‘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 dynamicA process, not a stateIt arises through, and enables, positive interactions between the personal and the socialIt is relational and is not just a property of the individualOur genetics may predispose us to have a more active engagement with our social environmentIdea of a virtuous circle
5 Concepts that link the personal and the social aspects of mental health Efficacy and engagementCapabilitiesResilienceRelationships and mutualityValued identities and statusesSocial contextsAccess to opportunitiesMeaning, purpose and valueImplications for education?
9 Dominant story ‘A bolt out of the blue’ A person is hit by a biochemical event thatimpacts on how they think, feel and behaveand 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 treatmentsCulture of complianceExperiences of mental distress have no meaning – just symptoms of an illnessNo connection with ideas of positive mental health
12 Starting to deconstruct ‘A bolt out of the blue’ Service user perspectivesFinding meaning in distress experiences / making connectionsNew 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 Symptoms of an underlying illnessAn expression of an unresolved ‘problem of living’.a cry for help in relation to ‘unliveable' past and/or present social circumstancesA way or expressing the inexpressible.A coping or survival strategythe best available way of dealing with painful or stressful experiences.Self harm, psychosis
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 neglectSocial context e.g. inequalities, discriminationGeneticsFamily dynamics and relationship difficulties
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)Racehigher 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 exclusionDefeat 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 abuseLoss of parent or significant otherEmotional neglectRelationship 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 dynamicsDiagnosed with schizophrenia in later life (%)Low‘Healthy’High1.5‘Dysfunctional’513
20 A word of cautionWe have a lot evidence as to what may be contributory factorsBUTPresence 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 ratesWhat seems to matter is having a ‘place in the world’ to recover intoStrong 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 disabilityStress / vulnerabilitySocial / traumaPowerlessness / empowerment
23 Social model of disability Emerged from disabled people’s movementShifts focus from individual pathology / tragedy / self-blameConceptual separation of impairment (physiology) and disability (what person is prevented from doing / being part of)Tragedy vs the Iron Lung Brigade
24 Social model of disability What is experienced as most disabling is not people’s 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 itselfHOWEVERMany 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 WhammyThe experience of mental distress (which may connect with experiences of discrimination and abuse)Stigmatising responses from friends, family, professionals and society at largeResponses can make mental distress worse
28 Stress / vulnerability model (Zubin and Spring) Social contextsLife eventsGeneticCurrent stressTransitionsResponsibilitiesBoredomBREAKDOWN
29 But we have strengths and resources as well as vulnerabilities and stresses
30 Likelihood of mental distress VulnerabilityResilienceCurrent stressorsSocial capitalLikelihood of mental distress
31 SOCIAL / TRAUMA MODELForms of mental distress as logical responses to traumatic circumstances and their longer term social implications(Plumb, 2005)
32 SOCIAL / TRAUMA MODEL LOW SELF ABUSE DEPENDENCY ESTEEM ABUSIVE GUILT/ RELATIONSHIPSGUILT/SHAMEDEPRESSIONOCDSELF-HATENEED TOCONTROLSOCIALISOLATIONANOREXIAANGERDISSOCIATIONAND PTSDSELFHARM
33 Powerlessness / empowerment Exposure to situations of unequal power underlie:Disadvantage and discriminationTrauma and abuseDefeat and entrapmentCurrent 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 resilienceChallenging stigma and discrimination(Re)negotiating the terms of relationshipsMaintaining / 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 scansExposure to new social environments may enable the brain to re-align pathways and biochemistry– but this may take timeMedication 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 TOPsychological adaptations(vulnerabilities and resilience)ANDPhysiological adaptations(hard wiring and hormone levels)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 resourcesOther stresses we may be dealing with at the same time
38 Putting it all together (3): Supporting recovery Developing a shared framework of understandingHolding and managing out-of-control aspects of experienceLearning new strategiesUsing medication if it works (preferably short-term)Making new adaptationsBuilding on strengths and resilienceAcknowledging and (sometimes) resolving issues that are contributing to vulnerabilityLearning 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 frameworksPositive mental health, resilience and recovery are core to the agendaAny framework of understanding must encompass the interaction between the personal and the social