The troubled relationship between psychiatry and sociology

Social psychiatry lives!

In this journal Ikkos examines the work of the American sociologist Owen Whooley, who argues that US psychiatry has gone through five paradigm shifts without defining the object of its own expertise. We look at the substance of Whooley's methods and assumptions and offer our observations on Ikkos's argument and conclusions.

Attitudes and beliefs of Tunisian High-School teachers about schizophrenia: The impact of vignette gender

BACKGROUND

Teachers have a crucial active role in provision of mental health services to students and fighting against mental health stigma in schools, hence their attitudes and beliefs toward mental illness should be assessed.

METHOD

We carried-out a cross-sectional study with a non-probabilistic sample of 304 higher secondary school teachers. We used a structured questionnaire in which a vignette describing an individual with schizophrenia was presented, and was followed by a series of stigma-related questions.

RESULTS

A substantial proportion of teachers endorsed stressful life events (79.6%) as a cause of schizophrenia, elicited feelings of discomfort (41.4%) and incomprehension (41.1%) with the person displaying symptoms of schizophrenia, and agreed that the person's condition will deteriorate even more (45.4%). Teachers perceived that the person described in the vignette is dependent on others, lacks will, is different from others and is unpredictable in 65.1%, 59.2%, 55.6%, and 49.7% of cases, respectively. In addition, 38.5% and 34.2% of teachers recommended turning to traditional healers and to a Sheikh or an imam of a mosque, respectively. Regarding gender effects, females with schizophrenia were regarded as more likely to be unable to make her own decisions and to be dependent on others than males, and were less likely to be recommended for seeking help from a family physician or to consult a psychiatric hospital than males.

CONCLUSION

In the light of our findings, raising awareness of teachers of the impact of mental health issues on students should be prioritized in high schools in Tunisia.

Perspective: Decolonizing postmodernist approaches to mental health discourse toward promoting epistemic justice

Currently, it is possible to observe a slowly (but surely) growing volume of claims seeking to disprove Foucauldian ideas about knowledge and power as overlapping basic theories of epistemic justice. Prompted by these claims, alongside adopting tenets of Critical Race Theory to address injustices inflicted upon people facing mental health challenges, I propose applying decolonizing deconstruction to Foucault's terminology, toward identifying opportunities to enhance epistemic justice, primarily in direct interventions in mental health services.

Institutional injustice: Implications for system transformation emerging from the mental health recovery narratives of people experiencing marginalisation

BACKGROUND

Institutional injustice refers to structures that create disparities in resources, opportunities and representation. Marginalised people experience institutional injustice, inequalities and discrimination through intersecting personal characteristics and social circumstances. This study aimed to investigate sources of institutional injustice and their effects on marginalised people with experience of mental health problems.

METHODS

Semi-structured interviews were conducted with 77 individuals from marginalised groups with experience of mental health problems, including psychosis, Black, Asian and minority ethnic (BAME) populations, complex needs and lived experience as a work requirement. These were analysed inductively enabling sensitising concepts to emerge.

FINDINGS

Three processes of institutional injustice were identified: not being believed because of social status and personal backgrounds; not being heard where narratives did not align with dominant discourses, and not being acknowledged where aspects of identity were disregarded. Harmful outcomes included disengagement from formal institutions through fear and mistrust, tensions and reduced affiliation with informal institutions when trying to consolidate new ways of being, and damaging impacts on mental health and wellbeing through multiple oppression.

CONCLUSIONS

Institutional injustice perpetuates health inequalities and marginalised status. Master status, arising from dominant discourses and heuristic bias, overshadow the narratives and experiences of marginalised people. Cultural competency has the potential to improve heuristic availability through social understandings of narrative and experience, whilst coproduction and narrative development through approaches such as communities of practice might offer meaningful avenues for authentic expression.

The social life of self-harm in general practice

Research engaging qualitatively with clinical practitioners' understanding of, and response to, self-harm has been limited. Self-harm offers a particularly compelling case through which to examine the enduring challenges faced by practitioners in treating patients whose presenting symptoms are not clearly biomedical in nature. In this paper, we present an analysis of 30 General Practitioners' (GPs') accounts of treating patients who had self-harmed. Our analysis demonstrates the complex ways in which GPs seek to make sense of self-harm. Illustrated through three common 'types' of patients (the 'good girl', the 'problem patient' and the 'out of the blue'), we show how GPs grapple with ideas of 'social' and 'psychological' causes of self-harm. We argue that these tensions emerge in different ways according to the social identities of patients, with accounts shaped by local contexts, including access to specialist services, as well as by cultural understandings regarding the legitimacy of self-harming behaviour. We suggest that studying the social life of self-harm in general practice extends a sociological analysis of self-harm more widely, as well as contributing to sociological theorisation on the doctor-patient relationship.

Beyond the Medical Model

The medical model continues to dominate research and shape policy and service responses to suicide. In this work we challenge the assumption that the medical model always provides the most effective and appropriate care for persons who are suicidal. In particular, we point to service user perspectives of health services which show that interventions are often experienced as discriminatory, culturally inappropriate, and incongruent with the needs and values of persons who are suicidal. We then examine “humanistic” approaches to care that have been proposed as a corrective to an overly medical model. We argue that the focus on improving interpersonal relations set out in humanistic approaches does not mitigate the prevailing risk management culture in contemporary suicide prevention and may impede the provision of more effective care. Finally, we draw attention to the tradition of non-medical approaches to supporting persons who are suicidal. Using Maytree (a U.K. crisis support service) as a case study, we outline some of the key features of alternative service models that we consider central to the design of more culturally appropriate and effective interventions. We conclude by making three key recommendations for improving services to persons who are suicidal.

Revitalizing sociology: urban life and mental illness between history and the present

This paper proposes a re-thinking of the relationship between sociology and the biological sciences. Tracing lines of connection between the history of sociology and the contemporary landscape of biology, the paper argues for a reconfiguration of this relationship beyond popular rhetorics of 'biologization' or 'medicalization'. At the heart of the paper is a claim that, today, there are some potent new frames for re-imagining the traffic between sociological and biological research - even for 'revitalizing' the sociological enterprise as such. The paper threads this argument through one empirical case: the relationship between urban life and mental illness. In its first section, it shows how this relationship enlivened both early psychiatric epidemiology, and some forms of the new discipline of sociology; it then traces the historical division of these sciences, as the sociological investment in psychiatric questions waned, and 'the social' become marginalized within an increasingly 'biological' psychiatry. In its third section, however, the paper shows how this relationship has lately been revivified, but now by a nuanced epigenetic and neurobiological attention to the links between mental health and urban life. What role can sociology play here? In its final section, the paper shows how this older sociology, with its lively interest in the psychiatric and neurobiological vicissitudes of urban social life, can be our guide in helping to identify intersections between sociological and biological attention. With a new century now underway, the paper concludes by suggesting that the relationship between urban life and mental illness may prove a core testing-ground for a 'revitalized' sociology.

Scientism as a Social Response to the Problem of Suicide

As one component of a broader social and normative response to the problem of suicide, scientism served to minimize sociopolitical and religious conflict around the issue. As such, it embodied, and continues to embody, a number of interests and values, as well as serving important social functions. It is thus comparable with other normative frameworks and can be appraised, from an ethical perspective, in light of these values, interests, and functions. This work examines the key values, interests, and functions of scientism in suicidology and argues that although scientism has had some social benefit, it primarily serves to maintain political and professional interests and has damaging implications for suicide research and prevention.

Beyond critique: rethinking roles for the anthropology of mental health

The current supremacy of the 'bio-bio-bio' model within the discipline of psychiatry has progressively marginalized social science approaches to mental health. This situation begs the question, what role is there for the anthropology of mental health? In this essay, I contend that there are three essential roles for the anthropology of mental health in an era of biological psychiatry. These roles are to (i) provide a meaningful critique of practices, beliefs, and movements within current psychiatry; (ii) illuminate the socio-cultural, clinical, and familial context of suffering and healing regarding emotional distress/mental illness; and (iii) act as a catalyst for positive change regarding healing, services and provisions for people with emotional distress/mental illness. My argument is unified by my contention that a credible anthropology of mental health intending to make a societal contribution should offer no opposition without proposition. In other words, any critique must be counter-balanced by the detailing of solutions and proposals for change. This will ensure that the anthropology of mental health continues to contribute critical knowledge to the understanding of mental suffering, distress, and healing. Such social and cultural approaches are becoming especially important given the widespread disenchantment with an increasingly dominant biological psychiatry.

The DSM: mindful science or mindless power? A critical review

In this paper we review the Diagnostic and Statistical Manual of mental health (DSM), its scientific bases and utility. The concepts of "normality," "pathology," and boundaries between them are critically reviewed. We further use the concepts of mindfulness and mindlessness, and evidence from cognitive and social sciences to investigate the DSM clinical and social impact and we argue against its assigned overpower. We recommend including alternative perspectives to the DSM, such as mindfulness and positive psychology. We also argue for including mindfulness training in psychiatric residency and clinical psychology programs.

Psychiatric epidemiology, or the story of a divided discipline

This article traces the historical decisions, concepts and key professional collaborations that laid the foundations for the formation of American psychiatric epidemiology during the 20th century, up to the discipline's institutional consolidation, circa 1980, when the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was published. Thomas Kuhn's 'disciplinary matrix' is mobilized as a framework that allows the institutional and intellectual construction of a discipline to be analysed as separate but intertwined components, without assuming that the two evolve in tandem. The identification of the strengths as well as the frailties and internal divisions of the discipline as it developed reveals a paradoxical situation: a time lag between psychiatric epidemiology's institutionalization and public recognition, on the one hand; and the weak coherence of its intellectual components, on the other hand. We briefly trace the origins of split among the discipline's aetiological models of mental disorders and suggest that the lack of coherence among them has prevented psychiatric epidemiology from achieving the status of a normal scientific discipline, in the Kuhnian sense. Without a more explicit attention to the intellectual rationale of the discipline, psychiatric epidemiology will continue to maintain a strong institutional dimension and weak intellectual matrix.

What is psychiatry? Co-producing complexity in mental health

What is psychiatry? Such a question is increasingly important to engage with in light of the development of new diagnostic frameworks that have wide-ranging and international clinical and societal implications. I suggest in this reflective essay that 'psychiatry' is not a singular entity that enjoins consistent forms of critique along familiar axes; rather, it is a heterogeneous assemblage of interacting material and symbolic elements (some of which endure, and some of which are subject to innovation). In underscoring the diversity of psychiatry, I seek to move towards further sociological purchase on what remains a contested and influential set of discourses and practices. This approach foregrounds the relationships between scientific knowledge, biomedical institutions, social action and subjective experience; these articulations co-produce both psychiatry and each other. One corollary of this emphasis on multiplicity and incoherence within psychiatric theory, research and practice, is that critiques which elide this complexity are rendered problematic. Engagements with psychiatry are, I argue, best furthered by recognising its multifaceted nature.

Gender differences in the knowledge, attitude and practice towards mental health illness in a rapidly developing Arab society

BACKGROUND

Mental disorders are common in all countries and cause immense suffering. Both gender and low socioeconomic status have been related to depression and other common mental disorders, but their possible relationship to mental health literacy remains uncertain.

AIM

The aim of this study was to determine the gender differences in knowledge, attitudes and practices towards mental illness in a sample of Qatari and other Arab expatriates residing in the State of Qatar.

DESIGN

This is a cross-sectional survey.

SETTING

Primary healthcare centres in the State of Qatar.

SUBJECTS

A multi-stage sampling design was used and a representative sample of 3,300 Qatari and other Arab expatriates above 20 years of age were surveyed during the period from October 2008 to June 2009. Of the study sample of 3,300, 2,514 subjects (76.2%) expressed their consent to participate.

METHODS

A questionnaire was designed to assess the gender difference in knowledge, attitudes and practice towards mental illness.This questionnaire was administered to the Arab adult population above 20 years of age who were attending primary healthcare centres for various reasons other than mental illness. Face-to-face interviews were based on this questionnaire, which included variables on socio-demographic characteristics, knowledge, attitude and practice towards mental illness.

RESULTS

Of the study sample, 49.2% were men and 50.8% were women. Overall, the studied women held more to the cultural beliefs related to some aspects of mental illness. For example, more women than men believed that mental illness is due to possession by evil spirits. Also, nearly half of the women thought traditional healers can treat mental illness; this belief was significantly lower in men. Some of the women considered people with mental illness as dangerous; a belief also significantly lower in men. Men had a better attitude towards mental illness than women. Men were more willing to visit a psychiatrist for their emotional problems, while women preferred a traditional healer. Women were more afraid than men to talk to the mentally ill. Knowledge of common mental illnesses was generally poor, and it seemed to be lower among women. Men obtained more information than women from the media; women favoured healthcare staff more than men did.

CONCLUSION

The study reveals that men had better knowledge, beliefs and attitudes towards mental illness than women. Most of the women were afraid and not willing to keep friendships with the mentally ill. The results of this study underline the importance of information in changing people's attitude towards mental illness. Recognition of common mental disorders was very poor in men and women.

[Hollingshead and Redlich: research on social class and mental illness fifty years after]

This article examines the book Social class and mental illness: a community study by A.B. Hollingshead and F.C. Redlich as it marks the fifty year of its publication. It highlights the role of these researchers who, with distinct educational backgrounds (sociology and psychiatry), were part of the pioneering group in the 1950s that initiated the construction of medical sociology. Their careful methodological work and the fact that they approached an unprecedented topic ensured the originality of their project. The article analyzes the research and its importance for sociology and psychiatry, with emphasis on the studies regarding social classes, using the bibliographies as the main sources, critical analyses made of the work and related studies.

Are We Medicalizing Women’s Misery? A Critical Review of Women’s Higher Rates of Reported Depression

Epidemiological research consistently reports that women experience higher rates of depression than men. Competing biomedical, psychological and sociocultural models adopt a realist epistemology and a discourse of medical naturalism to position depression as a naturally occurring pathology within the woman, caused by biology, cognitions or life stress. Feminist critics argue that this medicalizes women’s misery, legitimizes expert intervention, and negates the political, economic and discursive aspects of experience. However, the alternative model of social constructionism may appear to dismiss the ‘real’ of women’s distress, and deny its material and intrapsychic concomitants, as well as negate relevant research findings. A critical review of sociocultural and psychological research on women’s depression is conducted. It is argued that a critical-realist epistemology allows us to acknowledge the material-discursive-intrapsychic concomitants of experiences constructed as depression, without privileging one level of analysis above the other, in order to understand women’s higher rates of reported depression.

Biopolíticas da depressão nos imigrantes Africanos

Este artigo foca o tema controverso das biopolíticas da depressão em imigrantes, em particular nos originários da África sub-sahariana. Os sintomas depressivos, ligados à ansiedade, são identificados também pela nova e mais importante patologia mental dos imigrantes: a Síndroma de Ulisses, de stress múltiplo e crónico, já definido como "o mal do século vinte e um", e que atinge principalmente os africanos. Não só entre estes imigrantes mas também em África, segundo um estudo conduzido pela OMS, a depressão tornou-se uma das principais patologias mentais. O tratamento farmacológico do sofrimento, entendido como fenómeno orgânico, é considerado o único caminho possível, silenciando os processos históricos, políticos e socioeconómicos que lhe estão na base. A atenção é portanto focada na saúde mental do indivíduo, desviando-a de problemas sociais de difícil resolução, que necessitariam de respostas económicas e políticas.

The centrality of personal relationships in the creation and amelioration of mental health problems: the current interdisciplinary case

An interdisciplinary case is made for the centrality of personal relationships in the creation and amelioration of mental health problems. Taking the work of John Bowlby as a starting point, the article summarizes accumulating evidence from the past 50 years about the link between childhood adversity and adult mental health problems. Evidence is also reviewed about contemporary interpersonal impacts on adult mental health from natural social settings and in professional therapy. These empirical summaries are then discussed in the context of dominant trends in professional knowledge about bio-determinism within psychiatry and the emphasis upon models and techniques in professional and political advocates of the psychological therapies. It is concluded that the latter trends are diverting us from policies, which properly concede the importance of relationships for improving the mental health of the population.

Postmodernity and mental health

Contemporary Western societies are characterized by rapid social transformations, the scope and pace of which are unprecedented in comparison to previous eras. This new era is often referred to as "postmodern." Social theory suggests that such transformations influence multifarious processes related to psychiatry, including risk factors, help-seeking behavior, the clinical encounter, and clinical outcomes. I introduce and critically discuss five key themes that arise out of sociological analysis of postmodernity and that may have special relevance to psychiatry: (1) individualization; (2) social roles and self-identity; (3) the culture of expertise; (4) the transformation of intimacy; and (5) future orientation. Although extant work implicitly corroborates the importance of the identified themes as influences relevant to psychiatry, little work in psychiatry has explicitly applied these themes or investigated their impact. Further integration of these themes into research may give a fresh perspective on important issues pertinent to contemporary psychiatry.

The survival of psychiatric diagnosis

Past and current debates about applying medical diagnoses to psychological difference in society are examined. Beginning with a brief historical overview from antiquity to 'anti-psychiatry' and a summary of recent debates, the article then offers two case studies of common diagnoses ('depression' and 'schizophrenia'). The main challenge for social science is no longer about what is wrong with psychiatric diagnosis (that is now well rehearsed) but how to account for how and why it has survived. In answering this question about survival, inter-disciplinary work could attend to the pre-empirical positions of mental health researchers; the ways in which mental disorders are similar and different to physical disorders; and the interest work of different social groups defending or attacking psychiatric diagnoses in varying contexts.