Mental Health

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50 Signs of Mental IllnessA Beautiful MindA Beautiful MindA Bright Red ScreamA Casebook of Ethical Challenges in NeuropsychologyA Corner Of The UniverseA Lethal InheritanceA Mood ApartA Research Agenda for DSM-VA Slant of SunA War of NervesAbnormal Psychology in ContextADD-Friendly Ways to Organize Your LifeAddiction Recovery ToolsAdvance Directives in Mental HealthAggression and Antisocial Behavior in Children and AdolescentsAl-JununAlmost a PsychopathAlterations of ConsciousnessAm I Okay?American ManiaAmerican Psychiatric Publishing Textbook of Neuropsychiatry and Clinical NeurosciencesAn American ObsessionAngelheadAnger, Madness, and the DaimonicAnthology of a Crazy LadyApproaching NeverlandAs Nature Made HimAsylumAttention-Deficit Hyperactivity DisorderAttention-Deficit/Hyperactivity DisorderBeing Mentally Ill: A Sociological Theory Betrayal TraumaBetrayed as BoysBetter Than ProzacBetter Than WellBeyond AppearanceBeyond ReasonBinge No MoreBiological UnhappinessBipolar 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ChildrenEmotions and LifeEmpowering People with Severe Mental IllnessEssential PsychopharmacologyEssentials of Cas AssessmentEssentials of Wais-III AssessmentEthics and Values in PsychotherapyEthics in Mental Health ResearchEthics in Psychiatric ResearchEthics, Culture, and PsychiatryEverything In Its PlaceFamily Experiences With Mental IllnessFatigue as a Window to the BrainFear of IntimacyFinding Iris ChangFinding Meaning in the Experience of DementiaFlorid StatesFolie a DeuxFor the Love of ItForensic Nursing and Multidisciplinary Care of the Mentally Disordered OffenderFountain HouseFrom Madness to Mental HealthFrom Trauma to TransformationGandhi's WayGender and Its Effects on PsychopathologyGender and Mental HealthGenes, Environment, and PsychopathologyGetting Your Life BackGracefully InsaneGrieving Mental IllnessHandbook of AttachmentHandbook of DepressionHandbook of Self and IdentityHealing the SplitHerbs for the MindHidden SelvesHigh RiskHope and DespairHow Clients Make Therapy WorkHow People ChangeHow to Become a SchizophrenicHow We Think About DementiaHughes' Outline of Modern PsychiatryHumanizing MadnessHysterical MenHystoriesI Hate You-Don't Leave MeI Never Promised You a Rose GardenI Thought I Could FlyI'm CrazyImagining RobertImpulse Control DisordersIn Others' EyesIn Two MindsInsanityIntegrated Behavioral Health CareIntegrative MedicineIntegrative Mental Health CareIntuitionJust CheckingKarl JaspersKissing DoorknobsKundalini Yoga Meditation for Complex Psychiatric DisordersLaw and the BrainLaw, Liberty, and PsychiatryLegal and Ethical Aspects of HealthcareLiberatory PsychiatryLife at the BottomLife at the Texas State Lunatic Asylum, 1857-1997Life Is Not a Game of PerfectLithium for MedeaLiving Outside Mental IllnessLiving with AnxietyLiving With SchizophreniaLiving with SchizophreniaLiving Without Depression and Manic DepressionLost in the MirrorLove's ExecutionerLoving Someone With Bipolar DisorderMad in AmericaMad TravelersMad, Bad and 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Related Topics
Mental Health At The CrossroadsReview - Mental Health At The Crossroads
The Promise Of The Psychosocial Approach
by Shulamit Ramon and Janet E. Williams (Editors)
Ashgate, 2005
Review by Tony O'Brien, RN, MPhil.
Oct 31st 2006 (Volume 10, Issue 44)

The plethora of books presenting "models" of mental health and psychiatry is testament to the disputed nature of just what is going on when a person experiences mental distress that is outside the "normal" range, and especially what is going on when that person is diagnosed with mental illness. The more progressivist accounts of the history of psychiatry notwithstanding, this argument has been a feature of psychiatry since its formation as a discipline in the early nineteenth century. Psychiatrists have struggled to gain respectability for their discipline within the field of medicine, and for themselves as practitioners of a medical specialty. The waxing and waning of opinion in psychiatry can be seen in the rise and fall of various institutions, theories, therapies and movements within the broader field of "mental health". The asylum as retreat (pace Tuke), the institutional hospital, theories of degeneration, heredity and infection, moral therapy, psychoanalysis, insulin coma therapy, the therapeutic community, antipsychiatry, community care, all have had their hay day before falling into decline, some apparently gone forever. More recently we have seen sustained challenges to the medical model of psychiatry, in the form of consumer movements such as "recovery", and the contemporaneous resurgence of biological psychiatry.

Into this contested and divided field comes a new book, Mental Health at the Crossroads, and with it a plea for a new understanding of a previously used term, "psychosocial". Edited by social workers Shalamit Ramon and Janet Edwards, and with a forward by sociologist David Pilgrim, this diverse collection brings together contributions from psychiatrists, activist, social workers, nurses and service planners. The uniting theme is the conceptual framework outlined by the editors in the first chapter, a challenge to the domination of bio-medical understanding in mental health services, in the form of the psychosocial approach. It might seem that there is nothing new about such an approach. But the editors argue that the time is right for the psychosocial approaches of the past to again assert themselves, this time with an acceptance that social processes alone are not sufficient to explain the phenomena of mental distress, and that adequate weight needs to be given to the personal and subjective alongside the influence of factors such as gender, ethnicity and poverty.

Having spoken of a uniting theme, it is important to note that there is no unanimity of opinion in this book. In particular the editors are unable to fully accommodate the views of psychiatrist Duncan Double, especially as they, almost alone in this volume, wish to recognize a place for the biological, albeit much reduced when compared to its place in current models of mental health. The problem of reaching any accommodation with biology is perhaps one of the central problems for alternative discourses on mental health: Any acceptance of the biological is seen as something of a Trojan horse, an invitation to a reductionist discourse of exclusion. Ramon and Edwards' comment on this reveals a degree of skepticism that makes the chance of any accommodation unlikely.

"Arguing that biology plays a part in mental illness…seems commonsensical for creatures rooted within a body…Yet in the history of the medical model giving priority to biology has meant the denial of all else as of primary importance."

This stance is reflected elsewhere in the book, in chapters outlining the need for psychosocially oriented mental health services, to giving priority to user centered service development, and to the place of narrative in understanding mental distress.

The book has four sections outlined in the introduction. The first is the single chapter outlining the conceptual framework and is followed by sections on social policy, paradigms in psychiatry, and a final section on psychosocial interventions. Interestingly, the conceptual framework is developed in relation to a primary care based case study, not one of the problematic cases considered by the contributors who write about secondary services. This immediately signals that "mental health" is not understood within the silo-like framework of service provision which in most countries separates primary health care from care provided in secondary services. Health is given a broad definition in which the editors hope to give appropriate weight to psychosocial influences at a societal as well as individual level.

In the first chapter on social policy, Neil Foster uses a case study to examine mental health response to a man with bipolar disorder in three different countries, the UK, the US and Australia. This leads to a discussion of the dilemma that in expanding its remit into the community, psychiatry has also extended its social control function through the development of a range of means of compulsion which extend powers of legal coercion into the community, potentially eroding the broader agenda of enhanced citizenship for mental health consumers. Thus the historic tension between psychiatry as a clinical and administrative science is played out within the emerging model of citizenship, especially under the influence of risk consciousness. This theme is taken up by Healy and Renouf in the Australian context, and by Prior in relation to the UK.

The middle section of the book is titled "Paradigm shift" and so promises much in terms of teasing out a new model of mental health care. In fact the contributions are quite diverse, giving weight to different aspects of the reconcpetualization of psychiatry. Double develops his notion of a "biopsychosocial" model, clearly more concerned to find some form of conceptual bridge that will recognize the role of biology at the same time as limiting its admitted excesses. Mezzina considers the Italian experience, and stresses the role of community in the reintegration of people with mental illness. In the chapter by Vasconcelos we are reminded that mental health, by whichever model it is understood, is exquisitely vulnerable to macro-economic and political agendas. The case of Brazil shows how the greatest strength of a developing country, its informal networks of care, can be undermined by political instability, which in turn is influenced by international economic policies. Paradigm shifts are harder to achieve when the social and economic infrastructure of a country is under threat. Beresford uses the concept of "madness and distress" as an alternative to "mental illness", indicating, perhaps unsurprisingly, that language remains a site of contestation even amongst those who seek to redefine psychiatry. Beresford emphasizes a social model which, although he is at pains to recognize the role of the psychological, remains fundamentally driven by notions such as social role and rights. Beresford outlines a number of service initiatives that support the disability model.

In the final section of the book various contributors outline elements of new theory and practice. Wallcraft begins with a discussion of "recovery", perhaps the most widely used alternative discourse in psychiatry. In a somewhat mixed chapter Wallcraft doesn't clearly distinguish a preferred model of recovery; nor does she comment on the implications of a consumer movement appropriating one of medicine's central concepts. She does note that recovery has become a feature of several countries mental health policies, raising the possibility that its discourse of resistance becoming re-appropriated by the center, in much the same way "social psychiatry" lost its power to redefine relationships in psychiatry. Giddings and Borkman explore the role of self help groups in recovery, noting differences between the US and UK, and ending with a review of recovery from the US. Self help groups pose a direct challenge to medical dominance as they involve user groups in generating their own experiential knowledge, apparently without concern for theoretical positions. Families have long been crucial participants in mental health decision making, particularly in decisions to use mental health legislation. Rappaport reports on the UK situation where family members are given key roles, although as Rappaport points out, without those roles being adequately theorized. Rapporport proposes a model to aid the Approved Social Worker, the statutory official who must respond to families' concerns. Janet Williams contributes a chapter on trauma, covering both the trauma of sexual abuse and trauma of military conflict. She cautions that Western approaches to talking about experience may not be appropriate within some ethnicities. The continued, postinstitutional separation of mental health from the mainstream of health policy is reflected in Ramon's chapter on mental health promotion. Such is the legacy of pessimism from the institutional era, that mental health promotion only became an official part of UK health policy in 1999. Ramon discusses some of the problems and prospects for mental health based on a public health model, identifying a clear confluence of interest with the notions of social inclusion and empowerment. Jones and Gamble's chapter on psychosocial approaches in interventions for schizophrenia is a reminder that such approaches have been in place for more than a decade, with a theory base in psychiatry that goes back for some time before that. The psychoeducational model of the late Ian Falloon is part of mainstream psychiatry, illustrating the breadth of programs that earn the title "psychosocial". Barker and Buchanan-Barker's chapter ends the book where it might have begun: with the reconceptualiazation of madness as a quest for spiritual fulfillment; practitioners as guides who should check that they have the most useful maps.

Overall, Mental Health at the Crossroads, is a useful, although rather uneven book. While it is successful in bringing together a number of critiques of the medical model of psychiatry, they are a very diverse group indeed. The book demonstrates that there is much work to be done in developing mental health policy and practice to meet new challenges. It also gives a sense of the numbers of activists and professionals who are busy providing consumer focused services and working to achieve the contemporary vision of mental health as citizenship.

The promised psychosocial model remains somewhat elusive, except at a very general level. One has the sense of a loosely related series of chapters rather than a theoretically integrated book. Some of the editing also suggests that publication was an important agenda here, perhaps as much as developing a coherent theory. However there will be few consumers, practitioners or professionals who will not gain something from reading this book. Diversity can make for an unruly theory, but it does capture the conceptual and practical complexity of mental health practice.


2006 Tony O'Brien


Tony O'Brien, RN, MPhil., Senior Lecturer, Mental Health Nursing, University of Auckland,


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