ABSTRACT

Janet E. Williams and Shulamit Ramon This book was our response and challenge to the enduring status and domination of a bio-medical understanding and delivery of mental health services which, to quote from Roberto Mezzina’s chapter, appears to many stakeholders ‘superseded and anachronistic’. Worldwide there is an articulate challenge to this ‘neo-positivist’ illusion as well as alternative theories and practices; we have sought to give voice to this by inviting practitioners, academics and service users from Australia, Brazil, Italy, the UK, and USA to write from their standpoints in their area of expertise. They, like us, write not as critical theoreticians but with an active practical concern about the stigma and damage to individual’s lives that this ‘scientific’ and diagnosis based approach brings. The style of writing reflects the differing cultural sources, but all challenge an unthinking reliance upon a simplistic scientific notion of scientific/research evidence. The chapters are theoretical, polemical at times, with a clear exposition of the values and politics of a psychosocial approach. The title suggests an optimism that there is sufficient critical mass to challenge and make changes to this hegemonic paradigm. We are equally aware, and in fact illustrate in some of the chapters (Double, Healy and Renouf), that there have been such critical points in the past when new ideas and paradigm shifts have occurred. We present this collection with the intention of showing some of the history to this challenge, to illustrate trends, to elaborate upon movements still being shaped and to discuss theory with plenty of illustrations and case examples. We want this book to speak to a wide audience of service users and carers, theoreticians, policy makers, researchers, students and practitioners. The chapters are written with an enthusiasm and belief in the emancipation of service users, carers and practitioners; as well as in structural change alongside valuing the individual’s subjective and narrative experience. We have termed this way forward as ‘psychosocial’. Though used before, we use it here to illustrate a paradigm in which both are integrated. The social includes the structural elements of society, such as social class, ethnicity, gender and sexual orientation, which affect not only the prevalence of poor mental health but the opportunities to access appropriate services, to be listened to, to make ‘healthy’ changes to the social and physical environment, to move out of social exclusion or to escape from violence. It also includes the impact of culture on mental health and illness. Psychological perspectives bring these ideas into both the subjective and intersubjective spheres, help with aetiology, and direct us to understand individual’s and groups’ experiences or narratives, the ways that people cope and make sense of their lives. However the danger of a purely psychological approach can be to pathologise, extending notions of illness ever wider by dint of our

professional expertise fuelled by fear of risk taking, thus ignoring the breadth of ‘normality’ in society whether it be hearing voices, the extent of deprivation and poverty, or the incidence of women in abusive relationships. The book is presented in four parts. The new and old paradigms are presented by the editors in Part One – Mental Health at the Crossroads – to contextualise the book and draw out the key elements of a psychosocial approach. Part Two – Contextualised Social Policy: Agenda and Priorities – demonstrates how the psychosocial approaches are shaped, promoted or hindered by policy and legislation; the confusion of ideas and competing influences which play a role in policy formation. Part Three – Paradigm Shift: Processes and Outcomes – considers the paradigm shift in more theoretical detail whilst Part Four – The Psychosocial: Experience and Practice – illustrates the policy and theory in practice. Part One Mental Health at the Crossroads The first chapter, written by the editors, ‘Towards a Conceptual Framework: The Meanings Attached to the Psychosocial, the Promise and the Problems’, outlines the theoretical premise of the book and identifies issues discussed fully in the subsequent chapters. The ‘psychosocial’ is articulated and some contrasts made with other current models such as the bio-medical and the biopsychosocial. The psychosocial as used here denotes a demotion of the biological rather than a denial, and a subsequent questioning of the usefulness of bio-medical notions, such as ‘diagnosis’ and ‘cure’ in favour of terms that relate to people’s lives and experience. For this reason the chapter begins with a case study in which the real lived issues such as depression are presented. The significance of the interrelationship between the social and psychological is explored to develop a more sophisticated understanding of each together. The case study provides different understandings and responses and in this way the ‘existing hegemonic paradigm … its un-usefulness – either/or conceptually, methodologically, ethically and in everyday intervention’ (Mezzina) is revealed. This leads to the extrapolation of the new perspective in which the user/patient relationship with the practitioner is highly significant; a relationship that is both more complex and profound than in physical medicine and which challenges traditional perspectives on professionalism. In line with emancipatory practices, which characterise the new psychosocial approach, this relationship is finely tuned to the power differentials, to the person’s own life and becomes atypically ‘hands on’ in ways that rely upon the emotional/psychological availability of practitioners. Part Two Contextualised Social Policy: Agenda and Priorities This section of the book takes some of the common psychosocial themes and explores their adoption or otherwise through policy making in three countries, the

UK, USA and Australia. These themes include integrated support, health promotion and prevention, social inclusion and quality of life issues through whole community support, sensitivity to ethnicity and culture, gender, sexual orientation as well as civil rights and the right to treatment. The authors show how the impact of political responses, from neo-liberal government to de-institutionalisation, are now associated with ‘risk management’ or ‘risk aversion’ in these countries and how this conflicts with the emergence of the voice of service users and the psychosocial approaches noted above. Both positions can be legislated for in different ways, but protection and control are given greater weight than the rights of service users. As demonstrated this is a contested field with considerable complexity due to the range of stakeholders, the lack of consensus about the balance between individual rights and community protection, different paradigms about mental distress and subsequently differing emphases on interventions. Neil Foster’s chapter starts this section by exploring how the concept of risk has taken on new, negative connotations, which have seriously affected policy making. He applies this to a case study, in three national contexts. Bill Healy and Noel Renouf consider the conflicting standpoints in an Australian context and then Pauline Prior addresses them in the UK, with reference to Europe. Neil Foster takes risk as his starting point in the chapter entitled: ‘Control, Citizenship and ‘Risk’ in Mental Health: Perspectives from UK, USA and Australia’. He uses a case study to illustrate how at the level of service provision citizenship, service entitlement and control/community protection are managed in practice through legal frameworks. The three societies have different legal frameworks but there is considerable convergence around a ‘risk aversion’ agenda, with an increased focus on managerialism. He argues that the mental health professional, subject to more bureaucratic surveillance is much less inclined towards therapeutic risk taking. This has meant that the care/control balance is the major focus for most mental health practitioners. He points out the irony that concurrent with raised political expectations of public services and practitioners to manage risk has come a political challenge to, and subsequent erosion of, professional knowledge and expertise. He argues that risk has also become the eligibility factor for services so that those deemed ‘low risk’ are defined as ‘less eligible’. He shows how the dominance of risk and rationing, following on from the wider political agenda, have served to exacerbate social exclusion while at the same time the user movement, requiring practitioners and government to enhance service users’ rights, inclusion and services has been strengthened. The case study that follows is discussed in the policy and legal contexts each of the three countries in order to illustrate the tensions outlined above and the comparative differences. Healy and Renouf in their chapter, ‘Contextualised Social Policy: An Australian Perspective’ provide an overview of influences and policy. Like Prior in the following chapter they pull out two competing themes or ‘interests of progress’ operating in the ‘conflictual circumstances’ influencing these changes. They identify these in the Australian context as care and community concern on the one hand whilst on the other competing definitions of what constitutes the system’s

preferred mode of intervention with identified service users, within the context of the competing paradigms of the bio-medical or the psychosocial. The first National Mental Health Plan 1992 was constituted in order to improve services in response to de-institutionalisation. However the psychosocial interests embedded in it lost out to the seemingly more efficient medical interventions following a change of government and the subsequent neo-liberal reforms of welfare affecting working practices, reducing budgets. The second National Plan in 1998 reinstated the psychosocial aspects, reflecting World Health Organisation (WHO) guidance which stressed the burden of illness and that outcomes relate more to quality of life issues over levels of symptomology. They then outline the developments in their own State of Victoria using the same themes. They go on to show how the fear of those supported by community services has not been dispelled by governments in Australia, but taken on board for political reasons and identified as a risk to be legislated for. They argue that the legislation has been counter productive because the introduction of compulsory treatment in the community – community treatment orders – damaged the work with service users through jeopardising the collaborative relationships between them which is key to recovery and effective shared assessment. Also this approach relies upon managing the illness rather than the quality of life and ignores civil rights. They state that the preoccupation with risk infects the whole culture of mental health work. This has brought about a greater focus on the medical aspects for mental health and very little attention to social care and social provision. Prior gives a critique of current mental health policy in the UK from two similar contrasting and conflicting standpoints, one of rights and the other from risk and community protection, making links to similar debates within Europe. Within the UK she explores the ‘modernisation’ agenda since 1997, which has been introduced into all parts of government, welfare and health services. This is an agenda shared with the governments of most economically developed countries who have moved to community based mental health services with the effect, she says, of bringing them currently to a period of ‘radical change’. She notes how mental health policy, unlike the rest of health policy also reflects changes to policy about crime, law and order. Prior considers that the combination of these changes has exacerbated the sense of risk. In parallel is the second trend, the slowly developing influence of the user movement which has grown in strength since the 1980s and which has aimed to increased citizenship. She gives many examples of how the Human Rights Act, introduced from the European Union since 1997, should be supporting the claims of service users. The introduction of new Mental Health Act is likely to widen the scope of compulsory powers for enforced medication, following the Australian example. This has been criticised by almost all stakeholder as diminishing civil rights and because it is likely to be unworkable. This challenge to civil rights, mitigates against the worker/user relationship outlined as crucial in a psychosocial approach, as discussed by Foster, Healy and Renouf above, as well as by Ramon, Williams and in Wallcrafts’s chapter on Recovery.