See article Going Social: Championing a holistic model of mental distress within professional education

There is nothing new about social perspectives – in different ways, understanding the interrelation of ‘mental distress’ and ‘problems of living’ is something that has, for many years, been on the agenda of, among others:

• Identifying stressors in family and community living, e.g. expressed emotion – although drawing short of seeing these as potentially contributing to initial breakdown
• Importance of work and meaningful activity

• Links between personal trauma and distress, e.g. sexual abuse

• Impact of poverty, discrimination, social exclusion etc. on incidence of mental distress
• Concept of social capital
• Deviance, labelling theory and stigmatisation

• Framework for understanding interaction of social and intra-personal dynamics

• Practice based on awareness of power issues - value base of anti-oppressive practice and empowerment / partnership

• How problems of living and mental distress may be expressed and dealt with differently in different cultural contexts

• Need for holistic assessment e.g. Letting Through Light initiative

• Professionals do not listen to the whole of people’s stories, including the ‘mad’ bits
• Understanding ‘symptoms’ as survival mechanisms
• Social issues, e.g. poverty, isolation, lack of employment, housing, relationships, can be more of a priority day-to-day than managing psychiatric symptoms – getting a life together may itself be the single most important factor in reducing the negative impact of mental distress
• Mad Pride – assertion of ‘difference’ as positive, challenging negative valuation of ‘mentally ill’ identities

• Recovery depends on finding a way of understanding and giving meaning to experience that enables a person to reclaim control of what is going on for them
• Recovery is about claiming / reclaiming a socially valued lifestyle, and social empowerment, rather than becoming ‘symptom-free’

• Particular mental health issues for women and men, lesbians and gay men
• History of psychiatry buying into oppressive stereotypes in relation to gender / sexuality

• Social model of disability: it is society’s (and professionals’) responses to impairments, rather than the impairment itself, that can be most disabling.

Research based on longitudinal surveys shows that advances in pharmacology and other medical treatments have resulted in little consistent improvement in recovery rates – so we cannot say that the medical model, on its own, is a sufficient basis to underpin policy and practice in mental health. Instead, variables such as cultural setting and unemployment rates appear to have a much greater impact – and there is some evidence that socially oriented services achieve higher recovery rates. As Pat Bracken and Phil Thomas have argued in OpenMind,

It may be that medical technologies have a particular contribution to managing the acute phases of people’s distress, but both mental health promotion, and longer term action and support, may more effectively be guided by social perspectives.

What has not so far happened is for the various strands of alternative ‘social’ thinking, all of which have been to some extent in the shadow of the medical model, to be brought together as a coherent model (or set of models) in its own right – one that can, in its own way, be as influential on policy and practice as is the medical model.

The need for a more holistic approach is reflected in the National Service Framework for Mental Health, in which concepts such as social inclusion and recovery play an important role. This also recognises that a broader evidence base is required than that provided by evaluations of medical treatments.

February 2002 saw the launch of the Social Perspectives Network for Modern Mental Health whose aims are to:

• Articulate and promote the value of modern social models in mental health services
• Engage with and influence key policy makers to support the integration of social models within modernizing mental health services
• Provide a focus for the sharing of best practice in social interventions in modern mental health services

It is hoped that such thinking also becomes reflected in the work of the new National Institute for Mental Health, the Social Care Institute for Excellence and other bodies with a brief over research, policy, education and practice agendas.

However, although there may be a groundswell of interest in social perspectives, there is currently a lack of clarity as to what exactly is meant by a social model of mental health (if indeed it is a model that is required at all), and how such approaches could be more effectively implemented in practice.

I would argue that at the core of a social model are two parallel perspectives that link ‘mental distress’ with ‘problems of living’:

• In one sense, mental distress may represent a deployment of the best available set of coping or survival strategies that a person may be able to access.
• In another, mental distress may represent direct or indirect expressions of painful issues or injustices that may feel unresolved.

Thus, at one and the same time, it may constitute both an awesome story of survival in relation to an oppressive or ‘unliveable’ situation, and a desperate cry for help and understanding. Whether viewed as a coping strategy or as an expression of extreme disquiet, it may represent a way of being that is lived out at some considerable cost to the person, and may potentially pose difficulties or risks both to them and to those around.

• Need to have a framework that focuses on people’s relationships – to counter existing tendencies to individualise people’s difficulties
• Status of evidence – need to move beyond a knowledge base derived only from positivist ‘objective’ research
• Focus on needs rather than diagnoses / classifications
• Value base is as important as knowledge base in constructing a social model
• Need for social model to engage with issues of social control
• The pros and cons of having a ‘social model’ (or models):
• Danger of reducing complexity of peoples lives into a neat formula that mirrors the reductionist tendencies of the medical model, versus
• Need for a reasonably simple and coherent framework in order to underpin practice, or else we are left just with the medical model as the only framework.
• Whose views and experiences will be privileged in deciding what is important in a social model?

There was a strong consensus that this was just the start of a process of discussion.

Contacts for follow up discussion:

Social Perspectives Network

spn@topssengland.org.uk

Jerry Tew

Jerry.Tew@uce.ac.uk

Tew, J. (2002) Going Social: Championing a holistic model of mental distress within professional education. Social Work Education 21:2