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Expert analysis, debates and comments on topical policy-relevant issues

Shifting the public conversation on mental health – understanding the social conditions that shape private troubles

📥  health, policymaking

Professor Simone Fullagar is Professor of Sport and Physical Cultural Studies in the University of Bath's Department for Health

Mental health professionals, NGOs and a variety of service-user groups have all called for greater funding for local and global mental health services, as well as for greater parity of esteem between these services and broader health policy and service provision in the UK. The Mental Health Taskforce’s 2016 report details the need to address chronic under-spending on mental health services in the UK as demand continues to increase and inequalities widen. NHS spending is increasing in areas that support a medicalised response to mental health issues, with prescriptions for antidepressant medication doubling over the last decade in the UK. The taskforce’s report recommends a billion-pound investment in 2020/21 and calls for fresh thinking to shift cultural attitudes that stigmatise mental ill health as an individualised problem. Recently Theresa May announced a review of child and adolescent services in England and Wales and investment in mental health first aid training for schools. This is an important step, but how far will it go, given that from 2010 to 2015 there was a reduction of 5.4% in the funding of child and adolescent mental health services in the UK?

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Young people are a major focus of concern, as they suffer from high rates of depression, anxiety, eating disorders and are vulnerable to developing more severe and enduring conditions. National survey data indicates a worsening picture for young women (15-18), who have the highest rates of depression and anxiety in the UK. Suicide rates have increased, with young men experiencing higher rates of suicide than young women, who in turn have higher rates of hospital admission for self-harm. One in four (26%) women aged 16 to 24 identify as having anxiety, depression, panic disorder, phobia or obsessive compulsive disorder.

The case for greater funding for mental health services is supported by a growing body of evidence which points to the value of investing in appropriate support and early intervention. Recent psychological research in the UK identified how different therapeutic approaches (cognitive behavioural therapy (CBT) and psychosocial interventions) for adolescent depression have been found to have similar beneficial effects. Across different approaches there is a common thread emphasising the importance of developing a ‘therapeutic alliance’ with a young person so they are able to effectively engage with support (feeling heard and respected, avoiding further stigmatisation, being involved in coproducing services, etc). This question of what works best for young people with a range of needs and diverse social backgrounds is an important one, given the role of the Improving Access to Psychological Therapies programme in increasing access to psychological therapy via CBT as a technical formula. Research has identified that 40–60% of young people who start psychological treatment also drop out against advice. A high proportion of people also do not seek help from professionals despite the recurrence of common mental health issues. All these factors point to the complexities surrounding clinical and community-based mental health provision. A positive shift in recent years has been an increasing recognition of the importance of involving people with lived experiences in the coproduction of localised services that move beyond privileging biomedical treatments, and support a recovery-oriented approach (for example, the Wellbeing College for adults has been created in Bath).

While this focus on funding more personalised support is incredibly important for people experiencing all kinds of distress, we also need broader public conversations and policy approaches that offer a critical understanding of how private troubles connect with our public lives to acknowledge the social determinants of mental health. Mental health problems are associated with social injustice, marginalisation and the embodied distress of trauma – poverty, discrimination (class, gender, sexuality, ethnicity etc), poor housing, unemployment, social isolation, gender-based violence, childhood abuse and intensified bullying in the digital age. In the context of austerity measures and cuts to public funding across a range of areas, it is perhaps not surprising that private troubles and social suffering are exacerbated.

Mental health and illness are also highly contested concepts with diverse, and often competing, trajectories of thought about biopsychosocial causes and conceptualisations of distress. Public knowledge of ‘mental illness’ is historically shaped by our diagnostic cultures of psy-expertise (from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to digital self-assessments), the rise of brain science and research funded by Big Pharma, and the less-often-heard accounts of those with lived experiences (including a diverse range of identities – service users, consumers, and members of anti-psychiatry, hearing voices and mad pride movements). While there is often great media interest in studies claiming to identify the biological cause of problems in the brain (often visualised via high tech images), many people would be surprised to know that there are no specific biomarkers for ‘mental illness’ – and theories about why anti-depressant medication works for some people (and with similar effects to placebo and other non-pharmacological treatments), are based on hypothesis rather than fact.

If we look at the national data cited earlier we can see how gender figures as an important variable – yet there is a curious absence of gender analysis in the context of mental health policy and service provision despite the growing research in this area.  My own sociological research into women’s experiences of depression and recovery identified the often highly problematic effects of antidepressant medication that was prescribed to help them recover. Women spoke of how their embodied distress was heightened by side-effects, and how feelings of emotional numbness exacerbated their sense of ‘failing’ to recover despite following expert biomedical advice. Suicidal thoughts and attempts were evident alongside guilt about not living up to the normative ‘good woman ideals’ of self-sacrificing mother, productive worker or caring wife. Others identified a feeling of being paradoxically trapped in a sense of dependency on a drug that helped them to feel more ‘normal’ and thus able to manage the gendered inequalities and pressures of their lives with demanding caring roles, work or unemployment. Restrictive gender norms, experiences of inequality that intersect with class, ethnicity, religion, sexuality and age, as well as a lack of gender-sensitive provision within mental health services and beyond (childcare, housing, domestic violence support, access to low-cost community activities that support well-being) were key policy related issues. The policy challenge ahead of us is to understand the complexity of how mental health is affected by, and affects, all aspects of social life. Social science research has a unique contribution to making critical issues (such as gender inequalities) visible in the development of a whole range of approaches, decision-making processes about resources and public dialogue about how we understand the social conditions that shape distress and support wellbeing in the contemporary era.

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