Introduction

1.1 Definitions in mental health discussions You will now be introduced to four key professionals discussing mental health. Also, as a way of developing study skills, you will be asked to undertake note-taking exercises to help you think about the course content as a whole. Activity 2 Introducing Models of Mental Health Allow 1 hour Task A Meet the authors In this activity you will listen to an audio in which four people, authors of the book Models of Mental Health, introduce themselves and their professional roles and backgrounds. The first two people you will hear are Gavin Davidson and Jim Campbell, both social workers and professors of social care. Next there are two people with similar first names, the first Ciarán Shannon, a consultant and clinical psychologist, and the second is Ciaran Mulholland, who is a psychiatrist.

In the audio you will hear the authors describe the different professional roles in mental health services which they represent. The discussion then revolves around how understanding is still evolving and that the way in which language is used reflects this development. In the audio there is reference to ‘the module’, which refers to the OU course this OpenLearn course comes from. Before you start, you might find it helpful to refresh your note-taking skills using the following guidance: Academic-skills: effective note taking. Audio 1 SARAH VICARY Shall we begin with introductions of you as authors, your current role and interest in mental health? GAVIN DAVIDSON My name’s Gavin Davidson. I’m one of the four authors of Models of Mental Health. In terms of my, sort of, background and role, I trained as a social worker in Liverpool in the early nineties and then worked as a social worker in mental health services until about 2008, and then moved to Queen’s University in Belfast. My current role is Professor of Social Care, but my focus is still very much on mental health. And in terms of my interest in that area, it’s probably mainly because of family experiences – my dad had mental health problems – and also then an interest in social justice and human rights, which are central to mental health, I think. And also the complexity of the issues is fascinating. In terms of the book itself, I led on the introduction and the critical perspectives chapter. JIM CAMPBELL My name is Jim Campbell. In terms of my professional background, I was a mental health social worker in Belfast in the 1980s. Around that time I also happened to be a part-time tutor for The Open University in Northern Ireland and Ireland. After completing my practice as a mental health social worker, I taught, as Gavin did, in Queen’s University Belfast. Then I went to Goldsmiths, University of London, and finally just recently retired as Professor of Social Work at University College Dublin. And my interest … long-standing interest is in the area of mental health social work, mental health law and also social work and political conflict. CIARÁN SHANNON My name is Ciarán Shannon. I am a consultant clinical psychologist. I’ve always had both clinical and academic roles and that’s very similar today. I’m a consultant clinical psychologist who manages specialist psychology service in mental health in an NHS trust. And I’m also director of the trust research sector. My big interest in mental health is severe mental illness and psychosis in particular, and the links between psychotic experience and various types of adversity, including social adversity. CIARAN MULHOLLAND My name is Ciaran Mulholland. I’m a consultant psychiatrist. A psychiatrist, just in case any of the listeners are unaware, a psychiatrist is first and foremost a medical doctor, so psychiatrists train in medicine first and then they specialise in psychiatry. So I specialised in psychiatry now three decades ago, in the early 1990s. I have an interest too, as Ciarán Shannon just mentioned, in psychosis, the causes of psychosis, in particular the role of trauma and adversity in the causation of psychosis. More recently I have an interest in trauma more broadly defined, and in particular the consequences, the long-term consequences, of The Troubles in Northern Ireland. SARAH VICARY Thank you, everybody. What you’ve brought is a huge range of experience, which is fantastic for this module because what we’re trying to do is understand what is meant by mental health. We use the terms mental health and mental ill-health. How would you define these concepts? CIARAN MULHOLLAND Yes, well, perhaps I’ll start this, Ciaran Mulholland, and these concepts are used very widely now, not just by professionals but in wider society, and every day in the news and the media we see commentary and stories about mental health and ill-health. And that’s good. There’s much less stigma than there was in the past, people talk about mental ill-health more than they did in the past. But there is a lot of confusion around terminology and that can be difficult, especially for anyone who’s starting out on a career journey in a mental health profession or any health profession. What we’ve tried to do in this book is to bring together a range of concepts – concepts that we think that complement each other mostly, though sometimes they clash, but mostly they complement each other. The first chapter that I led on the book was the chapter around biomedical perspectives and that’s the chapter that does lay out what we sometimes call the traditional medical model. Now, doctors are trained to think about health and ill-health as being dichotomous, so either you’re well or you’re not well. So, for example, with regards to blood pressure, either your blood pressure is normal or your blood pressure is pathological. But I think probably most people are aware that that’s arbitrary. So, who’s to say that a certain blood pressure is abnormal and another blood pressure is normal? An abnormal blood pressure in one country could be deemed to be normal in another country. So we’re faced with a real problem in trying to define mental ill-health. But for a doctor, for a psychiatrist, our training, it is about a person being so far away from the normal experience, in the sense of the common experience of most people, that that means that there is pathology present – it’s about the presence of pathology. SARAH VICARY So this next question about your book, which aims to present a critical overview of the main theoretical perspectives relevant to mental health, and in it you’ve outlined six. In doing so, you suggest that there’s no single theory or perspective that provides a comprehensive framework. Could you please say a bit more about what you mean by this? GAVIN DAVIDSON Yes, thanks Sarah. It’s Gavin here. I think the sort of general approach or theme throughout the book is really to acknowledge that our understanding of mental health and mental health problems is still developing. It’s part of the reason why it’s such an interesting area to work in. And that all of the different perspectives that we cover, and many others, all have something to contribute to our understanding of mental health. It also reflects, perhaps, the concern that at times debates about mental health can feel divisive. Sometimes there’s a lot of energy devoted to debating the relative importance of different perspectives, and some of that’s very healthy and helpful and sometimes maybe it’s not so helpful. We’re trying to sort of communicate that we think all of these perspectives are important and useful and we should engage with them all – an acknowledgement that we still need to be very open. Our understanding’s still developing and our understanding of the central role of trauma in mental health. Even when we were writing the book trauma-informed care wasn’t as much of a focus as it is now, so it’s great to see that’s happening. SARAH VICARY Thanks, Gavin. You, in the book, have a perspective you term as the ‘service user-led perspective’. Can you say what you mean by this, its contribution, strengths and limitations? And, also, could you comment about the different terminology? JIM CAMPBELL Thanks very much, Sarah, this is Jim. And I think it’s a really good question to be asking. The way we use language in mental health services, in the way we describe mental illness, mental health and the experience of those who have mental health problems is quite contested actually. The book reveals some of those contested ideas. From my perspective and on my understanding of these different terms, I think we need to look at how they have developed historically since the rise of the Victorian asylum, the development of professional practices in the twentieth century and, more importantly, one might say, is the increasing voice of those who have experienced these services, And I think the way professionals use the terms is quite static and fixed even though people with mental health problems would like different terminologies to be used about their identities. So, I think doctors, nurses and other professionals in the medical arena would still refer to those people as patients. Social workers, I think, still refer to the people they help as clients. And the generic term, historically, is the term service user, and I think that’s quite a problematic term because it connotes that the person who’s receiving the service is somehow a user, which can be a negative connotation. So, I do think we should embrace these new terms and identities, the lived experiences of people who have had the services or experts by experiences. But ultimately the way we use language, and this is true for the other ideas we developed in the book, the way we use language and narratives about these issues is very contingent on individual and professional identities and issues of position and power. As you are listening, make notes on what the authors say about the different perspectives they bring to mental health and their own interest in it. You may also want to make notes about concepts that are introduced here such as stigma. Listen carefully to the discussion about language – this will help you with the next activity. Each of the authors in the audio speak briefly about their professional role and how they became interested in mental health. Gavin Davidson for example referred to his own personal experiences. Personal experiences of mental health are an important aspect of this course. Each of these professionals talk about different perspectives from their own viewpoint including social, medical and psychological approaches. As you were listening you may have made notes on what they are saying about the associated concepts. For example, Ciaran Mulholland talks about diagnosis and how fundamental this is to the medical perspective. Last the discussion turns to the use of language and how in this instance the various ways to which a person who may need help because of mental ill-health may have been referred over time. Task B Online dictionaries In the second part of this activity you are going to consider language in more detail and also learn how to use online dictionaries. There are a number of free online dictionaries available to you. Often, your digital devices have a dictionary app, too. It’s down to personal preference what you want to use for this activity. You might want to do a quick search on the internet for online dictionaries and try some out and then select the one (or more) that you get on with best. Here are some suggestions. You’re likely to come across the Cambridge Dictionary, Collins Dictionary, the Free Dictionary and the Merriam-Webster dictionary. They have different interfaces but essentially work in similar ways. Make sure you’re in the dictionary section or tab. Then type your search term into the search box and look at the results. You often get several definitions in your results list. Now select an online dictionary to search for the term ‘mental health’. Make a note of the dictionary you’ve used and of the definitions it provides. Then repeat this process with another online dictionary. Compare and contrast the findings of the two dictionaries. In this activity you started to explore the use of language associated with our understandings about mental health. There are a number of different ways of defining both mental health and its absence – which may be called ‘diagnosed mental illness’, ‘mental distress’ or ‘mental ill-health’. You were encouraged to think about the medical connotations that are raised by the words that are used to describe mental health and emotional distress. This may have already challenged some of the assumptions you may have previously held about the ways in which mental health is discussed and the impact this has on how mental health is considered. However, the world of mental health is typically made up of services and practitioners who come from the ‘psy’ disciplines, such as psychologists and psychiatrists, and you were introduced to two of these disciplines in the interview. Their ideas about the world fundamentally shape mental health practice and our responses to mental health problems. It is important therefore to understand some of the dominant or traditional models that are used in the ‘psy’ worlds of mental health, such as the medical and psychological models. In the audio you were also introduced to the social model, an approach which is equally important to consider. You will return to an audio of these four professionals discussing the different types of models later in this course. In the next section of the course you will explore some of these perspectives in more depth.

1.3 Approaches and models of mental health In addition to language and perspectives, approaches and models each help provide an understanding of mental health. Earlier you considered what a perspective is, and you will now go on to explore approaches and models. An approach is best understood as a way of dealing with a topic, while a model is a particular way of understanding an approach and which can be compared and contrasted. Activity 4 Approaches to identifying mental ill health Allow 30 minutes Read the following descriptions of subjective and objective experience written by OU academics. As you are doing so split your thoughts into the two main approaches of subjective and objective and identify main concepts within each. Reading B Box 1 Subjective experience There are two main approaches to identifying mental ill health. The first is to focus on a person’s subjective experience. That is, what does the person feel about, and how do they explain, their own mental and emotional state? This kind of subjective monitoring and reporting of our thoughts and emotions is an ongoing, everyday occurrence for most people, and is part of the way we construct and communicate a personal narrative about who we are and how we feel. As such, a person may be aware of the ups and downs they experience emotionally, and of the thoughts and feelings they find upsetting, uncomfortable or distressing. A person may also be aware that some of their behaviour choices – to drink alcohol to excess, use nonprescribed drugs, to work, or eat or sleep excessively, for example – may also be a way in which they express their underlying mental health problems. As such, it is necessary to find ways of facilitating and listening to a person’s own subjective account of their mental health and wellbeing in determining whether or not a mental health problem exists. This might mean an approach in which the practitioner gives someone time to talk, uses sensitive questioning or listens in an accepting, non-judgemental manner so that the individual can express themselves on their own terms. Box 2 Objective evidence The second approach to mental health problems is to seek more objective evidence of mental, emotional or psychological disturbance and abnormality. This kind of evidence tends to be sought by professional mental health workers following standardised medical or psychological procedures or using structured tests (Gelder et al., 2005). Objective measures of mental health problems might include: scans to assess brain structure and functioning blood tests to rule out physical conditions, such as anaemia, that might share some characteristics with, for instance, depression neuropsychological tests that test memory or problem-solving skills other structured behavioural observations that focus on a person’s pattern of behaviour. Objective evidence is often produced in the form of numerical and scientifically grounded results. As such, it does not directly take into account how a person feels or what they believe about their mental health and wellbeing. Given that a person’s own subjective understanding is relevant to whether what they are experiencing is a mental health problem, diagnosis of mental health problems tends to occur when both the subjective and objective evidence fit together to confirm a particular set or pattern of symptoms The world of mental health is filled with a wide range of perspectives and approaches. These can also have an impact on the way in which those experiencing mental ill-health may seek help. An individual’s partner, friends, colleagues and family members play an important part in promoting and supporting their mental health and wellbeing. These are often also the people an individual will turn to when they first disclose or seek help for their mental health problems. The informal support provided by partners, relatives or friends within a person’s family and social network may be enough to help them. Where this is not the case, a person may require assessment, treatment and support from one or more mental health services and the professionals who work within them. Having explored perspectives and approaches in mental health, you will now go on to consider models. Activity 5 Models of mental health Allow 45 minutes Listen to the audio of our four professionals introducing a range of perspectives starting with social, moving on to medical and psychological. Make some notes on the different perspectives as you listen. Audio 2 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. Social perspective There are three concepts discussed concerning the social perspective and model. You will have heard that social ideas of mental health are very important in understanding the lived experience and it is recognised that social contexts and factors have an impact on mental health and wellbeing. Although it is possible to understand how social events can lead to mental ill-health (a famous 1978 study by Brown and Harris about women is mentioned), causality is a difficult thing to decide. The second aspect to consider is the notion of social responses or social theory – the concept that giving people labels because of mental ill-health can cause difficulty for them. Last, there is the concept of social construction – the idea that behaviour and thought is socially constructed but changes in time. Ideas of mental ill-health are viewed differently in different societies. Social or critical realism and how we describe mental health focuses on the way in which language is used and understanding difficult realities are mediated by how professionals describe these experiences. Medical/biomedical model This perspective is discussed in terms of making a diagnosis using a collection of signs and symptoms. However, there are no tests of particular relevance and an example of a depressive illness is discussed. Having a diagnosis can have many benefits – for example, it might tell us something about causation, but this is also non-specific. Diagnosis does not exclude that there may be social causes; again, an example is provided – in this instance it may be that women living alone are more likely to become depressed, but there are also biological and genetic factors to take into account. Diagnosis can also suggest an outcome and risks involved if not treated. It can provide some clarity and reassurance. However, diagnosis can also be problematic, as the process is generalised. There is also a risk that treatment may not work, which could be disappointing to the individual. Psychological perspective In this explanation it is suggested that psychologists are not particularly focused on what is ‘wrong’ or the causes of mental ill-health, they are concerned with processes that are internal to the individual and underlying distress in its various forms. Psychologists use various theories, such as attachment and cognition, to try to describe the distress, and there are lots of therapies available. The disadvantage of this approach is that it locates the problem within the individual and ignores societal and other adversities, which also need to be acknowledged. However, it can give the individual strength in being able to try to respond to their situation. Spirituality is also mentioned, and an interesting discussion takes place about mental health services being secular. Religious and spiritual perspectives are hugely important and can promote healthy behaviours and provide support and meaning, although the opposite can also be the case, as issues such as the internalisation of shame can be unhelpful. Core teaching point Core perspectives underpin this course. These include three traditional models: social medical psychological Other models, which are not discussed in this course, include the psychotherapeutic, religious, spiritual and biopsychosocial models. Having considered how different perspectives impact on our understanding of mental health and in turn the language and models that exist, you are now going to take the opportunity to look back at how these perspectives may have developed over time in England and Wales.