# Transcript

SARAH VICARY

So, welcome back to our discussion. Having discussed the different perspectives, you argue it’s important to consider the contribution, strengths and limitations of the range of different ideas. I would like to discuss each of the perspectives in turn. First, we’ve … we’re looking at the social perspective.

JIM CAMPBELL Thank you, Sarah, this is Jim. Social ideas are very important to try and und… to use and understand the lived experiences of people who have mental health problems. It’s widely recognised in the literature that social context and factors have various impacts upon mental health and wellbeing. In the book chapter, we borrowed on the … from the ideas of a very seminal book by Pilgrim–Rogers and their influential ideas on how social ideas can help us understand how mental health problems occur, even how they might be resolved. We used three themes or ideas or concepts. One was the idea of social causation, and this is where there might … it might be possible to understand how social factors or social events can lead to mental ill-health or mental illness. And the literature often refers to a famous study by Brown and Harris about depression and women who are socially isolated in urban contexts and that was one example of where researchers tried to determine how social isolation can lead to depression causally. But causality, as we know in research, is quite a difficult issue to finally pin down. And there are other types of ideas in this area that I think are helpful. One is the notion of societal responses, and this is drawn from interactionist social theory. And the idea here is that, once labelled or once a diagnosis is given to a person, that creates some sort of social opprobrium, some difficulty in terms of the label which is very hard to shake off. And regardless of what the person thinks themselves, the diagnosis somehow creates difficulties for them in wider societies. Another good idea or concept which is used in the social models debates is one of social construction. It’s quite complex but perhaps I can simplify it to some extent by saying that this suggests that the idea that behaviour of thought is somehow socially constructed and changes in time, for example, in terms of how the classification system in mental health service, in mental health services, changes in time to capture some behaviours and thoughts in one epoch and then at a later epoch it disappears. And we know that our ideas of serious mental illness or other types of anxiety disorders are viewed quite differently in one society when compared to other societies. And then, just finally, Bhaskar theorists came up with or discussed an interesting middle point which is called social or critical realism, which helps to try and help us understand mental illnesses. But how we describe those things is often determined by the way we use language, the way professionals use language. And so, this sort of middle … middle area of the social model debate is interesting because it helps us understand that there is a reality out there that is really painful and stressful and difficult for people who experience mental illness – it is reality. But those realities, our understanding of those realities, are mediated by the way we describe those experiences and how professionals describe those experiences. So, just to conclude, mental illness and experiences of mental health are quite complex and we can use social ideas to understand how they may … how these experiences are created or mediated in society.

SARAH VICARY

Thanks very much, Jim, that was a really helpful explanation of the social perspective. I think Ciaran is now going to go and do the same for the medical or biomedical model.

CIARAN MULHOLLAND

Yes, thank you, this is Ciaran Mulholland and I’m looking at this from a psychiatric perspective. Jim has mentioned the term diagnosis and that’s what this is about, it’s about making a diagnosis. So what do we mean by a diagnosis in mental health? Well, essentially we mean a collection of signs and symptoms and then an impact on function of the signs and symptoms that are primary. There are no tests in psychiatry of any particular relevance – so if we take depression or depressive illness, there are not tests, it’s all about a collection of signs and a collection of symptoms. So we talk to the person, they tell us about their mental state and they explain that they’re feeling very low and very depressed. Now that’s, on one level, easy to understand because we’ve all been low or sad at some time in our lives as somebody close to us has died, for example. But a depressive illness is something beyond normal sadness, it’s usually deeper and more long-lasting, more persistent and goes on for longer and is accompanied by other associated symptoms, for example, loss of appetite with weight loss, hopelessness, inability to sleep, especially waking up early in the morning and not being able to get back to sleep again, and a sense of hopelessness which can go so far as to lead to suicidal thoughts, suicidal plans and suicidal actions. So, we say this person meets criteria, diagnostic criteria, for diagnosis of depression for all of the different conditions like schizophrenia. Now, the benefits of a diagnosis are many in my opinion. Firstly, it does tell us something about causation. So, we make a diagnosis of depression, it tells us something about why that person is in the room or is attending mental health services. But it’s non-specific. So we know that depression, there are social causes. Jim’s mentioned some of these already, the, you know, the studies that tell us that women who are isolated, living alone with young children, for example, in poverty are more likely to become depressed – so it tells us about social causation. We understand that depression has psychological aetiological factors, and we understand that there are biological aetiological factors in the sense of genetics, so some people are more likely to become depressed than others because of their genetic inheritance. So, it tells us about causation, it tells us about the likely course and outcome. So if somebody has a deep, depressive episode, a depressive illness, they are likely to remain depressed for a considerable period of time without treatment; and we know that there are risks involved if they are not treated. But most importantly, a diagnosis points us in the direction of treatment. Somebody has a depressive illness, then they are likely to respond to antidepressants and/or psychological interventions. And it tells us something about the prognosis – we can say to the individual, this is what is likely to happen. So, often a diagnosis brings clarity and reassurance, and many members of the public who come to mental health service appreciate that. But, of course, there are problems, there are limitations. The diagnostic process is often not particularly individualised, it’s very generalised and the person might feel, ‘I’ve been squeezed into a box here’, ‘this isn’t really me’, ‘doesn’t really describe me’. They might be disappointed by the treatment outcome – that they’re told an antidepressant will help you because you have depression. It turns out the first antidepressant doesn’t work and the second one doesn’t work and the third one maybe doesn’t work either and that can only lead to disillusionment, to think, well, that wasn’t a very helpful process for me. And the causation issue is important, because whilst we can comment in a very general sense about causation, what causes depression, what has caused depression for a particular individual at a particular point in their life, sometimes that’s a bit harder to pin down. So there are strengths and weaknesses, but in general the diagnostic approach, I think, is helpful and is adopted by most professionals on a day-to-day basis. But it’s very important that we are able to step away from it and make sure that we’re thinking about the person holistically, and as who they are. Final point: Jim’s already mentioned the question of labelling. So, a diagnosis, it is a label and a label … a label can help in certain ways, people sometimes like a label because they can understand themselves better, but often it’s not helpful in a sense of all the sort of eddies and currents and attitudes in society and in the family circle and the work situation that are not helpful.

SARAH VICARY

And we’re moving on now to Ciarán to look last at psychological perspectives.

CIARÁN SHANNON

Sure. Ciarán Shannon here again. What do we mean by psychological perspectives? Psychologists don’t tend to be terribly focused on diagnosis and what is actually wrong with you or rather the experience of distress in its various forms. And if you see distress as having a number of causes such as biological, social or circumstantial, i.e. events in people’s lives, in between those two things are psychological processes that are internal to the individual. And that’s what the psychological model focuses on: the psychological processes underlying distress in various forms. We use a variety of theories, from psychodynamic theories to behavioural theories, to cognitive behavioural theories, to attachment theories, to try and describe those psychological processes. It’s become hugely popular, I guess, in the last number of decades, and there’s been an explosion of psychological therapies available to people, especially in the UK. It does have one huge disadvantage because it does locate distress within the individual rather than within a society and within society structures. So, you know, if poverty, if discrimination, if marginalisation are the cause of psychological distress, it actually might do some harm to tell the individual that actually it’s how they are responding to these adversities that are the problem rather than the adversity. So that’s a huge difficulty. On the other hand, that’s also its strength because it gives control and power to the individual to respond to their circumstances, it’s … or processes … it’s both a huge weakness but also a huge strength.