Contemporary Mental Health

Theory, Policy and Practice

Barbara Fawcett, Kate Karban

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134334285
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

The authors explore theoretical developments and policy and practice initiatives in the complex and changing area of mental health services. They examine the tensions, dilemmas and opportunities now operating, including those relating to gender and ethnicity and places the involvement of users/survivors centre stage.Identifying and discussing the tensions between different professional models, varying 'social' perspectives and political imperatives, the book explores how these tensions are manifested in practice. Key topics include:

• the emphasis on risk as opposed to citizenship and entitlement
• social exclusion and inclusion
• professional and user perspectives
• the 'territories' of health and social care and their respective roles and relationships.

An important theme running throughout is the critical appraisal of perspectives concerning gender, ethnicity and sexuality, drawing out wider issues of power and inequality. This book makes ideas and theoretical policy material accessible and applicable, and is a key text for students and practitioners in mental health, social work and social care.

1 Introduction

Madness! Madness!

(Closing line to The Bridge on the River Kwai 1957).

What is ‘madness’? What is ‘sanity’? These are questions that have preoccupied philosophers, physicians and more recently psychiatrists, psychologists and sociologists. In a similar vein, when we talk about these areas are we talking about health and by definition mental health and ill-health or something else? If we focus on mental well-being or health, when does mental ill-health become illness? How are the dividing lines between those regarded as mentally healthy or mentally ill drawn and what part do prevailing ideologies, social and cultural practices and belief systems play in understandings, definitions and identification processes? These are all questions that will be explored in this book as theoretical and historical underpinnings of current ways of thinking are examined, prevailing policy is appraised and the implications for practice and for those utilizing current service provision are reviewed.

As a major aim of the book is to enable the reader to navigate the complex terrain that is occupied by understandings of ‘mental health’, emphasis is placed on the route from theory to policy to practice and back again. In order to facilitate critical reflection, it is not the intention to provide a new model or paradigm, but to provide accessible links between practice and praxis which incorporates the identification of conceptual signposts. It is argued that it is not so much ‘what’ individuals understand and apply, but ‘how’ they make connections between theory, policy and practice and ‘how’ they make dynamic and flexible use of knowledge, skills, values, analysis and evaluative methodology, that ought to be the object of attention. As part of this flexible map, individuals are charged with both locating the ways in which they are positioning themselves and locating the ways in which they are positioned by the operation of prevailing power relationships and paradigms. The experience of all individuals including those who utilize as well as those who provide services is important here. This is not to interpret experience as something that can be applied in a universalistic and standardized way to all situations, but to view it as an attribute which needs to be reflexively applied in a situationally specific manner. It is also important that the paradox, tension and inconsistency which can be seen to be integrally contained within policy and practice are not glossed over, but emphasized to draw attention to difference and diversity and the variety of conceptual paradigms operating.

However, at the outset, it is important to look at the current terminology used, the implications of the various names and labels and why particular terms have been chosen for this book. Clearly any exploration of this area immediately raises ontological and epistemological questions about how the questioner understands ‘madness’ and ‘sanity’ and the ways in which knowledge frameworks are applied. Taking this on board, terms and phrases in current usage include mental health, mental ill-health, mental illness, severe psychological distress, mental distress, problems with living, and madness. Those perceived, or who perceive themselves, to be experiencing difficulties can use or have applied to them a range of terms with the most common being ‘patient’, ‘ex-patient’, ‘client’, ‘service user’, ‘user’, ‘consumer’ and ‘survivor’. The terms used influence how an individual or group is viewed and how they view themselves. Labels and associated dichotomies, such as psychiatrist/patient, service provider/service user, easily become entrenched with expert opinion being regarded as the legitimate form of knowledge and forms of experience being ignored and marginalized. These distinctions similarly fail to highlight that ‘mental ill-health’ or ‘mental distress’, albeit in varying forms and to different degrees, is experienced by everyone. Some manage distress alone or informally with the assistance of family or friends, some choose or have chosen for them more formal support either privately or through publicly funded services. The form that this support takes can vary between professionally supervised drug treatments, talking therapies and alternative approaches such as becoming a member of the ‘Hearing Voices’ network, or a combination. There is also the issue of involuntary detention and/or treatment to consider. Some argue that this is never justified and that the criminal and civil laws that apply to everyone are all that is required (for example, Szasz 1971; Grobe 1995). Others maintain that the protection of the public and the self-protection of the individual diagnosed as having a ‘mental disorder’ have to be prioritized (for example, Howe 1995). Barnes and Bowl (2001) steer a course between these positions. They state: ‘It is important to recognise that there are times when uninvited interventions may, in the long run, be capable of creating the conditions in which empowerment is possible and a failure to act on the part of mental health workers is the most destructive response’ (2001: 4).

This overview draws attention not only to the difficulties associated with defining ‘mental health’ or ‘mental distress’ but also to the current overriding emphasis on medicalized understandings and practice responses. However, in this context, it is all too easy to set up a categorical distinction between ‘medical’ and ‘social’ orientations or Eurocentric and non-Eurocentric perspectives and to imply that there are rigid divisions, a lack of overlap, an absence of shared features, or that one should be prioritized over another. Rather than going down this particular path, this book is concerned with exploring the meanings associated with, to use the broad-brush term, mental distress,¹ utilizing critiques which draw from wide-ranging forms of analyses. Adherence to one perspective or one model is eschewed in favour of concentrating on the importance of the ongoing interrogation of situational factors, of broader-based understandings and the acknowledged and unacknowledged value judgements which inform action and practices. This is not to downplay the significance of mental ill-health/mental distress as such. Wilson and Beresford (2002) when discussing the socially constructed nature of mental illness assert: ‘we do not wish to deny or play down the very real mental and emotional distress that we and other psychiatric system survivors experience. We nevertheless view this as part of a broader continuum of distress and well-being: a continuum upon which all people would place themselves, in different positions and at different times in their lives’ (2002: 144). This is the view adopted in this book with regard to how both individual experience and constructing processes are both acknowledged and appraised.

The effects and consequences of increasing globalization and associated debates in relation to understandings of mental distress also require attention at this point. Discussion about the nature and consequences of globalization are wide-ranging. Initially driven by economic concerns and critiques directed at the cost of the welfare state, strongly regulated economies and high taxation systems, attention has increasingly turned to issues related to the standardization of policies and practices in a wide range of areas. However, Fook (2002) points out that one of the difficulties, but also one of the challenges, of understanding globalization is recognizing the ways in which world-scale changes have different and contradictory expressions in different contexts. With regard to the maintenance of cultural differences in the face of encroaching globalization, Kirmayer (2001) acknowledges that in relation to psychiatry, culture influences the sources, symptoms and idioms of distress, as well as individuals’ explanatory models, coping mechanisms and help-seeking behaviour and their social responses to distress and disability. Bhungra and Mastrogianni (2004) contend that, despite the influence of mass media and electronic telecommunication, widespread homogenization with regard to cultural understandings of mental health is not taking place. This they attribute to the process of globalization affecting only a minority and being counteracted by the reassertion of ethnic identities. They regard an increase in urbanization with its related rootlessness as being associated with globalization, but see this as having a wider-ranging significance with regard to the causative aspects of mental distress. These perspectives draw attention to the implications of globalization being far from straightforward and key aspects will be referred to throughout the book.

STRUCTURE OF THE BOOK

This book is divided into two main sections. The first, entitled ‘Theory, policy and tensions’, incorporates Chapters 2, 3, 4 and 5. These explore the theoretical underpinnings to current understandings in the arena of mental health and appraise the historical and contemporary policy framework. In this section issues of inclusiveness and exclusiveness are examined, with particular attention being paid to the influence of gender and ethnicity. The embedded tension, paradox and inconsistency apparent in the current policy framework are also subject to critical scrutiny. The second section, entitled ‘The changing contemporary scene: forwards – backwards?’, contains Chapters 6, 7 and 8 and explores both innovative developments and revisionary practices. In this context, the contribution made by the user/survivor movements is appraised and the impact of users/survivors repositioned as experts, is reviewed. In turn, the changing roles of workers and professionals within reconfigured organizational forms are interrogated and the opportunities and constraints incorporated within multi-disciplinary and multi-agency working are subject to critical scrutiny.

With regard to the content of specific chapters, in Chapter 2, the various understandings of mental health and the ways in which these understandings have influenced policy and practice, are critically appraised. This chapter explores a wide range of theoretical orientations which have been applied to mental distress. Rather than attention being paid to particular perspectives and adherents of these perspectives, there is a concentration on the work of a selection of commentators who accept that mental distress can be variously understood and responded to and who have put forward multi-faceted ways of exploring this contested area. The frameworks and analyses produced by Clare (1988), Pilgrim and Rogers (1999), Sayce (2000) and Horwitz (2002) are put forward as warranting further examination because all, in different ways, have engaged with a range of diverse models and conceptualizations. The critical appraisal of these multi-dimensional analyses is used to draw attention to three main themes which continue to inform the book as a whole. The first of these examines whether there are identifiable conditions or forms of behaviour which can be categorized in a particular way. This is in turn link to debates about social constructionism and social realism. The second is concerned, not so much with whether a condition is ‘real’ or ‘constructed’, but with how an individual associated with a condition or problem is responded to and the responses available. This is related to how a user/survivor is positioned and how users/survivors in turn can position themselves and others. The third theme explores how diagnosis and the medical confirmation of distress as an illness can be double-edged in that it can reassure and benignly explain the behaviour of ‘patients’ to themselves and others whilst also confirming vulnerability and the need for both ‘care’ and ‘control’.

Chapter 3 provides an historical overview of mental health policy with emphasis placed on highlighting those prevailing themes which impact on the contemporary picture. In this chapter, the shifts and changes in thinking about mental well-being, mental health and illness are acknowledged, together with the continuing influence of concerns about risk and dangerousness. In particular the changes which have taken place since the decline of the asylums and the shift away from an ethos of institutionalization towards care in the community, are explored. Current mental health policy is located within the wider picture of health and social care and the development of a mixed economy of care, marked by the NHS and Community Care Act (1990). It is noted that many of the developments initiated by the Conservative government have remained in place since 1997 when the Labour government commenced its ‘modernization’ agenda. The obstacles to reform and the tensions inherent in this process are set out as a platform for further debate in Chapter 5.

Chapter 4 acknowledges the recognition that prejudice, stigma and fear have been and remain a significant part of the experience of people who have mental health difficulties. In this chapter the various challenges to prevailing views are identified. These include the impact of policies associated with community care and de-institutionalization, with the accompanying rise of consumer rights, user involvement and participation; the development of critical psychiatry and the survivor movement; and wider challenges to the oppression of minority and marginalized groups by means of anti-racist, anti-sexist movements and disability rights organizations. An important aspect of this discussion is to unravel the various dimensions relating to oppression and discrimination, especially with regard to ethnicity and gender, which underpin the broader picture. Methodological issues are considered as part of a review of the over-representation of black and minority ethnic groups in certain more controlling aspects of service provision and the concomitant under-representation of such groups in primary care services and therapeutic/support services (Fernando 1995; Sainsbury Centre for Mental Health [SCMH], 2002). Additionally, the gendered nature of mental health, which permeates throughout theoretical discussions, policy developments and practice, is examined (Prior 1999; Payne 1998; Wilton 1998). Recent initiatives in England concerning the needs of women and men from black and minority ethnic groups are also explored (Department of Health [DOH] 2002a; DOH 2003c).

Chapter 5 examines the contemporary policy and practice framework. In this context, the impact of Modernising Mental Health Services: Safe, Sound and Supportive (DOH 1998) is appraised and the influence of the National Service Framework for Mental Health (DOH 1999a) and The NHS Plan (DOH 2000b), together with other legislative developments, are examined. The picture presented is that New Labour has energetically tackled entrenched problems in the field of mental health. They have set in motion a comprehensive system of clinical governance which incorporates a systematic setting of standards with milestones and performance indicators and monitoring processes. The importance of training and professional self-regulation has been emphasized and they are trying to address recognized shortfalls in provision and resources whilst asserting the value of ‘joined-up’ thinking and partnership working. They have taken steps to involve service users, paying particular attention to women and those from black and minority ethnic backgrounds, and measures have been introduced to safeguard the public and to foster the social inclusion of those with mental health problems by means of welfare-to-work policies, the Disability Discrimination Act 1995 and the 2005 proposals for a commission for equality and equal rights. It is argued that it is inevitable that such an ambitious programme will contain inbuilt tension, paradox and inconsistency. It is also contended that new policies or those which are presented as such are not introduced in a vacuum, but have to ‘bed down’ with those which have gone before. Again tension, paradox and inconsistency become inevitable as old policies, practices and cultures either form an explosive mix with the new or, to use an analogy drawn from geomorphology, provide a further layer with associated elevations, depressions and points of erosion. An examination of these areas, which include the opposing themes of managing risk and promoting social inclusion, the pull between local and centralized models of service delivery, the emphasis on evidence-based practice versus the tailoring of services to meet individual needs, and the various challenges posed to the prevailing mental health framework from those who have experience of mental distress, is also used as a means of constructively critiquing current policy.

Issues relating to users/survivors are considered throughout the book, but Chapter 6 takes forward some of the main themes. It explores the history and development of the survivor movement and considers the impact of this movement in the field of mental health. In particular, the development and application of the social model of disability, initially developed with regard to physical disability and subsequently related to mental illness, is explored. The notion of ‘recovery’ (Allott and Loganathan 2002), as a concept conceived of by survivors rather than by professionals, is appraised together with the recognition that there is a tendency for such developments to be integrated and diluted within mainstream policy. The increasing recruitment of people with experience of service use to work in mental health services is also reviewed together with the varied perspectives on involvement which include campaigning, the development of user-led services and involvement in current service developments. Related to the idea of an approach to recovery which ‘aims to support an individual in their own personal development, building self-esteem, identity and finding a meaningful role in society’ (Allott and Loganathan 2002: 4) is the concept of citizenship. This somewhat overused and variously defined concept is interrogated and the varying operational implications are scrutinized.

In this chapter it is clearly acknowledged that although there are areas of overlap, the interests of service users and carers have to be considered separately. Since the early 1990s, carers have featured prominently in government policies and their financial importance in terms of saved expenditure on public services has been acknowledged. However, often ‘carers’ are regarded as a distinct entity with emphasis being placed on homogenous rather than on heterogeneous factors. This chapter looks at dimensions relating to gender, age, class and ethnicity and unpacks stereotypical assumptions. The various understandings of mental health held by these diverse groupings are also reviewed and the implications for policy and practice are appraised.

Chapter 7 takes an historical perspective across the various professional groups involved in mental health care, including psychiatry, nursing and social work. It focuses on the development of the respective roles and the boundaries between the various components of the workforce. The implications of these roles for relationships between workers and those they are working with are explored as part of a discussion looking at the purpose and implications of what has historically been presented as a clear-cut, albeit dynamic, distinction. Similarly, the impact of recent policy and practice directives is examined. Key areas focused on include the changing organizational context of health and social care services as well as the shifting patterns of workforce configurations influenced by the drive towards occupational standards and competence frameworks (with an emphasis on a flexible and multi-skilled workforce, DOH 2000a; SCMH 2000). The increasing introduction of non-professionally aligned support workers in a variety of posts and settings is also considered within what may be seen as a move towards ‘deprofessionalization’, although the value placed on such workers by service users and carers is acknowledged (SCMH 1997; Burns et al 2001). This chapter raises a number of questions concerning the future of the mental health workforce including who is best equip...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• Dedication
• Acknowledgements
• 1 Introduction
• Theory, policy and tensions
• 2 Theoretical underpinnings
• 3 The historical policy framework
• 4 Inclusiveness and exclusiveness
• 5 Contemporary policy Tension, paradox and inconsistency
• The changing contemporary scene Forwards–backwards
• 6 User/survivor involvement and ‘carers'
• 7 Experts and allies – workers, professionals, service users and carers
• 8 Change, collaboration and multi-agency working
• 9 Conclusion
• Bibliography
• Index