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Social perspectives on severe mental distress

Jerry Tew

Reader in Mental Health and Social WorkUniversity of Birmingham

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Social perspectives on severe mental distress

Ways of understanding mental distress

Contributory factors and build-up: models and research

Social responses to mental distress

Recovery and what may enable this

Positioning of social work

Questions and discussion

How do we understand mental distress?

One account became dominant in the late 20th Century

historically and culturally specific

mental distress to be seen as a ‘technical’ issue that should be resolved by the application of science

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THE BIOPSYCHOSOCIAL MODEL

BIO PSYCHO SOCIAL

‘A bolt out of the blue’

A person is hit by a biochemical brain event that

impacts on how they think, feel and behave

and has implications for their family life, employment, friends…

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‘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 treatment, care and surveillance

Some implications of ‘A bolt out of the blue’

Experiences of mental distress have no meaning or connection with social experience just symptoms of an illness

People are powerless to do much about mental distress – except for accepting medical treatments

Culture of compliance

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Emerging critiques (and alliances): critical psychiatry “For 150 years, psychiatry has fanned the

flames of public hope and expectation, holding out promises of ‘cure’ and treatment for an ever-wider range of complex human and social problems. But these promises have failed to materialise… We believe that psychiatry should start a ‘decolonisation’, a phased withdrawal from the domains that it has laid claim to, including psychosis, depression and PTSD, by admitting the limited nature of its knowledge” (Bracken and Thomas, 2001)

Emerging critiques (and alliances): clinical psychology

For “psychiatric diagnoses such as schizophrenia … there is substantial evidence for psychosocial factors in aetiology, and very limited support for a disease model”(‘Position Statement on the Classification of Behaviour and Experience in Relation to Functional Psychiatric Diagnoses: Time for a Paradigm Shift’, Division of Clinical Psychology, British Psychological Society, 2013 p.2)

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Emerging critiques: research findings and personal experience

Model does not work very well in practice – Western recovery rates much lower that in some other societies – e.g. Kerala (Warner, 2004)

Service users have not been convinced that their experience is meaningless – e.g. Hearing Voices Network

Positive life changes (e.g. getting back into mainstream employment) can lead to reduction in level of ‘symptoms’ (Burns et al, 2009)

So how about the ‘lived experience +socio-psycho-bio’ model?

SOCIAL PSYCHO BIO

LIVED EXPERIENCE

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Towards a new story

What role do social factors play in serious mental distress?

What tips us over the edge?

A different starting point

Mental distress is a potentially meaningful response to challenging social and personal circumstances

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The biological and the social connect – but we may need to conceptualise this in a different way (Tew, 2011)

Evidence from brain scanning shows that Early childhood experiences of trauma

or deprivation can become reflected in the ‘hard wiring’ of neural pathways in the brain

Brains remain ‘plastic’ and positive life (and therapeutic) experiences may lead to positive ‘re-wiring’ in later life

Reconceptualising the relationship between social experience and biology Our genetic make-up and our social experience

may lead us to respond to situations in particular ways – and these response patterns result in vulnerability

and resilience

These response patterns (e.g. learning to trust; hearing voices) can be reflected in the hard-wiring and biochemistry of our brains – and exposure to positive social experiences may

enable the brain to re-align neural pathways

Medication can work for some people as a way of managing certain aspects of their distress at particular times– but may also get in the way of recognising and

resolving underlying issues.

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Mental distress may be understood as (Tew, 2011):

1. An expression of an unresolved ‘problem of living’.

Social defeat / trauma / powerlessness (Brown et al, 1995; Read et al, 2004)

Not being able to deal with unease Indirect signal that all is not well /

‘intermediary language’ (LeFevre, 1996)

2. A coping or survival strategy the best available way of coping in the face

of otherwise ‘unliveable’ painful or stressful experiences (Dillon, 2010).

The build-up:Stress / vulnerability model (Zubin and Spring)

Vulnerability

Current stress

BREAKDOWN

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But actually it is a bit more complicated….

We also have positive experiences

And can develop resilience out of negative experiences

Vulnerability Resilience

Stress and powerlessness

Social capitalSocial support

Likelihood of mental distress

The build-up

+ +

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And actually it can get really complicated….

We have all sorts of experiences and reactions

SOCIAL / TRAUMA MODEL (based on Plumb, 2005)

ABUSE

ANGER

SELF-HATE

GUILT/SHAME

NEED TO CONTROL

LOW SELFESTEEM

DEPRESSION

SELFHARM

OCD

ANOREXIA

DISSOCIATION AND PTSD

DEPENDENCY

ABUSIVE RELATIONSHIPS

SOCIALISOLATION

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Research evidence: some of the social factors that contribute to vulnerability

Poor educational attainment; unemployment (Fryer, 1995)

Being brought up in a poor and socially disorganised neighbourhood (Harrison et al, 2001)

Maternal loss in childhood; looking after >three children under the age of 14; unemployment (Brown and Harris, 1978)

Relative inequality and deprivation (Dohrenwend, 2000; Wilkinson and Pickett, 2009)

Trauma (Read et al, 2005; Larkin and Morrison, 2006)

Power and identity issues contributing to vulnerability and stressDiscrimination and oppression:o Race

higher incidence of ‘schizophrenia’ among African-Caribbean people in UK (but not in Jamaica) (Fearon et al, 2006)

Gender / sexuality over-conformity to or rebellion against gender

stereotypes (Read, 2004)

Heterosexism and homophobia (Jorm et al, 2002)

Sexual and physical abuse (inc bullying)(Read et al 2005; Sourander et al, 2007)

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Impact of family life on mental health: ‘Expressed emotion’

Exposure to particular patterns and emotional dynamics may influence the likelihood of relapse (Kuipers et al, 2006) Can relate to level of stress experienced by

family members Termed high ‘Expressed Emotion’

Actually what can be most detrimental tends to be: intrusiveness and over-involvement hostility – including simmering or covert

hostility (i.e. high unexpressed emotion).

How important are social factors?

When all other factors are taken into account, incidence of psychosis can be: 9x higher for people of African Caribbean

descent living in England (Fearon et al, 2006) 7x higher for people brought up in deprived

economic backgrounds as children (Harrison et al, 2001)

Information about frequent bullying and victimization at school age identified 28% of those with a psychiatric disorder 10 to 15 years later (Sourander et al, 2007).

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Impact of genetic and social factors on adoptees (Tienari et al, 2004)

Genetic risk Family dynamics

Diagnosed with schizophrenia in later life (%)

Low ‘Healthy’ 0

High ‘Healthy’ 1.5

Low ‘Dysfunctional’ 5

High ‘Dysfunctional’ 13

Social factors – what can happen after you become mentally distressed?

Social model of disability: What may be experienced as most

disabling is not people’s impairment, but societal responses to it.

Stigmatisation: Demonisation of mentally distressed

as “a menace to the proper workings of an orderly, efficient, progressive, rational society” – Roy Porter

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The ‘triple whammy’ (Tew, 2011)

1. Distressing mental experiences (which may connect with prior adverse social circumstances)

2. Stigmatising or distancing responses from friends, family, professionals and society at large

3. Others’ responses can make social circumstances even worse and this can impact on severity of mental distress

The recovery movement

Recovery involves resolving personal and social issues and ‘getting a life’ rather than just ‘taking the pills’

Connecting with others Hope for the future Finding positive personal and social

Identities Meaning and purpose Empowerment (Leamy et al, 2011)

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Social experience and recovery – what do we know?

Key processes in recovery include (Tew et al, 2012):

Empowerment and being able to take more control over one’s life

Supportiveness and mutuality in personal relationships (Topor et al, 2006; Schon et al, 2009)

Social inclusion / participation Reclaiming positive personal and social

identities

What seems to matter most is having a ‘place in the world’ to recover into (Bradshaw et al, 2007)

How important are social factors in longer term recovery? Population level evidence:

In West during 20th century: no correlation between recovery rates (social

and clinical) and the introduction of new forms of treatment

strong correlation with economic cycles.

Recovery rates can be 2x higher in low and middle-income countries where there are limited mental health services and (perhaps) people may be quickly re-inserted within family and community life – and expected to make a contribution (Warner, 2004)

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A conceptual model for recovery and social inclusion

Social engagement

Mental distressAnguish,

disconnection and powerlessness

Personal journey

Finding a place in the world

•Positive self identity•Connectedness

What makes recovery possible: underpinning resources (capitals)

Personal capital Education, dispositions, coping strategies

Relationship capital Mutuality, trust, acceptance

Identity capital Positive and coherent sense of self; valued social identities

Social capital Supportive network of ‘useful people to know’

Economic capital Income and ability to earn; purchasing power

Tew (2013) Recovery capital: what enables a sustainable recovery from mental health difficulties?

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Some research evidence

Size of social network and respondents’ subjective rating of its supportiveness are predictors of recovery outcomes (Mattson et al, 2008; Hendryx et al, 2009)

Getting back into mainstream employment (with support) can lead to improvements in wider social functioning and reduction in level of ‘symptoms’ (Burns et al, 2009)

Being able to choose one’s options in terms of social participation makes an important difference (Mezzina et al, 2006)

What happens when you have socially inclusive mental health services?

Long term evaluation of Open Dialogue in Finland (Seikkula et al, 2011):

81% of patients did not have any residual psychotic symptoms

84% had returned to full time employment or studies.

Only 33% had used neuroleptic medication

Even better than Kerala!

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PRACTICE: WHERE SOCIAL WORK SHOULD BE AT THE HEART OF CHANGE

Inclusive ways of working Whole family approaches

E.g. Open Dialogue, Family Group Conferencing

Whole systems approaches to recoveryCommunity action / community development

Social engagement, education, employment

PRACTICE: CHANGING THE POWER RELATIONS

Co-productive and asset/strengths–based ways of working

Working with people to (re)build the forms of capital that may be necessary to underpin recovery:

Personal, Relationship, Identity, Social and Economic

Intentional Peer Support, Recovery Colleges Personal budgets (Tew et al, 2015)

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So could this model be the future for mental health services?

SOCIAL PSYCHO BIO

LIVED EXPERIENCE

Your comments and questions

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References Bracken, P and Thomas, P (2001) Post-psychiatry: a new

direction for mental health. British Medical Journal 322:724.

Bradshaw, W et al (2007) Finding a Place in the World. Qualitative Social Work 6(1):27-47

Brown G and Harris, T (1978) The social origins of depression. London: Tavistock

Brown, G. et al, (1995) Loss, humiliation and entrapment among women developing depression: a patient and non-patient comparison. Psychological Medicine 25:7-21

Burns, T, et al (2009) The impact of supported employment and working on clinical and social functioning Schizophrenia Bulletin 35(5):949-958.

ReferencesDillon, J (2010) The tale of an ordinary little girl.

Psychosis 2:79–83.Dohrenwend, B (2000) The role of adversity and

stress in psychopathology: some evidence and its implication for theory and research. Journal of Health and Social Behavior 41(1)1-19

Fearon, P et al, (2006) Incidence of schizophrenia and other psychoses in ethnic minority groups: results from the MRC AESOP Study. Psychological Medicine 26. 1-10

Fryer, D (1995) Labour market disadvantage, deprivation and mental health. The psychologist8(6):265-72.

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ReferencesHarrison, G et al (2001) Association between

schizophrenia and social inequality at birth: case -control study. British Journal of Psychiatry 179: 346 - 350.

Hendryx , M, Green, C and Perrin, N (2009) Social support, activities and recovery from serious mental illness: STARS study findings. Journal of Behavioural Health Services and Research 36:3 320-329

Jorm, A et al (2002) Sexual orientation and mental health: results from a community survey of young and middle-aged adults. British Journal of Psychiatry180 423-427

Kuipers, L et al (2006) Influence of carer expressed emotion and affect on relapse in non-affective psychosis. British Journal of Psychiatry 188 173-179

ReferencesLarkin, W and Morrison, A (2006) Trauma and Psychosis

New Directions for Theory and Therapy. RoutledgeLefevre S (1996) Killing me softly. Self-harm: survival

not suicide. Gloucester: HandsellLeamy M et al, (2011) (2011) A conceptual framework

for personal recovery in mental health British Journal of Psychiatry 199:445-452

Mattsson M et al (2008) Association between financial strain, social network and five-year recovery from first episode psychosis. Social Psychiatry and Psychiatric Epidemiology 43 947-952

Mezzina, R, et al (2006) The social nature of recovery: discussion and implications for practice. American Journal of Psychiatric Rehabilitation 9:63-80

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ReferencesPlumb, S (2005) The social / trauma model. In J Tew (ed)

Social Perspectives in Mental Health. Jessica KingsleyPorter, R (1987) A social history of madness. London:

Weidenfield and NicholsonRead, J, Mosher, L and Bentnall, R (eds) (2004) Models of

Madness. Brunner Routledge.Read, J et al (2005) Childhood trauma, psychosis and

schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatrica Scandanavica112(5):330-350

Schon U-K et al, (2009) Social relationships as a decisive factor in recovering from severe mental illness. International Journal of Social Psychiatry 55(4):336-47

References Seikkula, J. et al (2006). Five-year experience of first-

episode nonaffective psychosis in open-dialogue approach. Psychotherapy Research, 16(2):214–228

Sourander, A et al (2007) What is the early adulthood outcome of boys who bully or are bullied in childhood? The Finnish "From a Boy to a Man" study. Pediatrics120(2):397-404

Tew, J (2011) Social approaches to mental distress. Palgrave Macmillan

Tew, J et al, (2012) Social factors and recovery from mental health difficulties: a review of the evidence. British Journal of Social Work 42:3 443-460

Tew, J (2013) Recovery capital: what enables a sustainable recovery from mental health difficulties? European Journal of Social Work16:3 360-74

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ReferencesTew, J et al (2015) ‘And the stuff I‘m able to achieve now

is really amazing’. The potential of personal budgets as a mechanism for supporting recovery in mental health. British Journal of Social Work 43(s1):i79-i98

Tienari, P et al (2004) Genotype–environment interaction in schizophrenia-spectrum disorder: long-term follow-up study of Finnish adoptees. British Journal of Psychiatry, 184:216–222

Topor A, et al (2006) Others: the role of family, friends and professionals in the recovery process. American Journal of Psychiatric Rehabilitation 9(1):17-37

Warner, R. (2004) Recovery from schizophrenia: psychiatry and political economy. (3rd ed) Routledge.

Wilkinson, R and Pickett, K (2009) The spirit level. Penguin.

ReferencesZubin J and Spring R (1977) Vulnerability: a new view

of schizophrenia. Journal of Abnormal Psychology 86(2):103-24