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, a.obrien@auckland.ac.nz

Categories: MentalHealth, Philosophical