‘Underfunded mental healthcare in the NHS: the cycle of preventable
Without early intervention in the community and continuity of care, people with mental health
conditions will continue to be failed by services’ writes Rachel Bannister in the British Medical Journal
The Social Model of Disability and Mental Health Activism
Over the last twenty years, the social model of disability has been increasingly recognised as an important theoretical framework for disability in the context of disability scholarship, activism and policy. A model of disability formulated by disabled activists during the 1970s and 1980s, the social model offers a critique of socially naturalised medical explanations of disability to expose and challenge the way inequitable social arrangements function to limit the life prospects and lived experience of disabled people (see Barnes and Mercer, 14). The social model has been widely adopted by disability advocacy organisations and charities with the aim of effecting change in disability rights legislation and challenge ableism at a wider societal level. However, more recently, the social model has been gaining traction within mental health activism and policy. This blog post will address the significance of the social model of disability in a mental health context. It will summarise the social and medical models of disability and mental disorders and consider the main advantages as well as some potential disadvantages for transporting a social model of disability formulated by disabled activists wholesale to the context of mental health activism. The concluding section of the blog post will propose some alternative ways of conceptualising the social model of mental distress which may have a bearing upon mental health activism and policy.
The Medical Model of Disability and Mental Disorders
To fully comprehend the distinction between the medical and social models of disability, it will be necessary to address the medical model of disability and mental disorders in some depth. While the medical model of disability and mental disorders may seem self-evident as the standard, socially naturalised explanations of disablement, unpacking medical understandings of disablement will lay the groundwork for explicating the social model by foregrounding some key points of distinction between the medical and social models that may otherwise be missed. A definition of disability given in The World Health Organisation’s International Classification of Impairments, Disabilities and Handicaps (1980), a manual which was designed to facilitate the classification of disease and disablement, encapsulates the medical model of disability. In 1980, the World Health Organisation defined disability as a “restriction or a lack (resulting from an impairment) of ability to perform an activity in the manner which is considered normal for a human being” (WHO 1980). As such, the medical model of disability conceptualises disability as a reduction in normal levels of functioning that arises as a consequence of an individual’s bodily or cognitive incapacity. In a similar vein, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) published by the American Psychiatric Association, the primary manual for the classification of mental disorders in use by the psychiatric profession, defines a mental disorder as a
syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning (20).
As such, the medical model of physical or psychiatric disability conceptualises reductions in functioning on the part of a given disabled person as the inevitable and incontrovertible result of a deficiency or deviance at the level of the individual’s body or mind.
On the medical understanding of disability put forward in the 1980 World Health Organisation handbook, a wheelchair user’s inability to access a public library which has a series of steps at the entrance, is positioned as a result of the individual’s limited physiological functioning. Similarly, according to the psychiatric understanding of disablement, the inability of an individual diagnosed with Obsessive Compulsive Disorder to use a public bathroom is constituted as wholly a consequence of the individual’s abnormal cognition and social functioning, rather than a failure on the part of public spaces and facilities to accommodate the needs of diverse needs of members of the human population. The conventional medical model of disability constitutes a disabled individual’s incapacity to participate fully in social life as an inevitable outcome of a ‘natural’ biological or neurobiological difference, which is judged as abnormal, and hence inferior, in character.
Insofar as the medical model locates disability in the individual, medical diagnosis and intervention is designed to ‘correct’ and normalise the individual. Medical diagnosis and treatment emphasise how individual bodies deviate from a normative standard, which is taken to be prior to social, cultural and historical norms and practices (see Tremain 86). The DSM-5 highlights the relevance of cultural considerations during the process of clinical assessment, noting, for example, that:
[…] assessment must therefore consider whether an individual’s experiences, symptoms, and behaviours differ from sociocultural norms and lead to difficulties in adaptation in the cultures of origin and in specific social or familial contexts (DSM-5, 14).
However, while the most recent edition of the DSM foregrounds the relevance of cultural considerations in the process of clinical diagnosis, it constitutes patients’ apparent failure to align with norms of their “cultures of origin” as maladaptive i.e. as evidence of underlying neurobiological deficit(s) (DSM-5 14). Furthermore, the process of psychiatric classification and assessment involves scoring patients’ symptoms against standardized rating scales which are assumed to provide objective and clinically neutral indicators of psychopathology. As William J Penson notes, this explanatory framework for mental disorders assumes that if a psychiatric “phenomen[on] is infrequent when measured […], it is abnormal by dint of its relative rarity” (59). However, as Penson suggests, it is not self-evident that psychological phenomena which are statistically anomalous within a given population are necessarily pathological in nature (59). By conflating psychological variation with pathology and abnormality, psychiatric practice obscures the extent to which value judgements are involved in the process of establishing diagnostic categories and in clinical decision-making more generally.
Historical shifts in the definitions of mental disorders attest to how cultural value judgements underlie the process of formulating diagnostic categories. The history of the psychiatric conceptualisation of homosexuality and asexuality is particularly revealing in this regard. As non-normative sexual preferences and practices, homosexuality and asexuality have historically been constituted as pathological or as indicative of broader personality psychopathology within the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM missing citation). To the extent that homosexuality was listed as a disorder within the DSM I and II (Drescher 571), homosexuality was effectively constituted as a psychiatric disability, which prevented those so afflicted from participating in normative social life and its most foundational institution, reproductive heterosexual marriage. However, homosexuality, as a diagnostic category, was reformulated and ultimately removed from the DSM in a series of moves beginning with the publication of the DSM II in 1973 (Drescher 571). The wholesale removal of homosexuality from the DSM-III-R in 1987 signalled the acceptance of a sexual orientation or minority sexual preference model of homosexuality on the part of the APA (see Drescher 571).
Similarly, asexuality, which is generally defined as an absence of sexual desire or attraction (Flore 65), has been pathologized within the DSM. Behaviours, affective states and modes of relating to others which are consistent with asexual identification have historically fallen within the remit of several different diagnostic categories such as “sexual aversion disorder” (SAD), “inhibited sexual desire” (ISD), “hypoactive sexual desire disorder” (HSDD), “male hypoactive sexual desire disorder” (MHSDD) and “female sexual interest and arousal disorder” (FSIAD) (DSM-III-R; DSM-III; DSM-IV-TR; DSM-5). However, whereas some disorders of reduced or absent sexual interest or function listed have since fallen into disuse, the most recent edition of the DSM (DSM-5) retains HSDD and FSIAD as diagnostic categories that list deficient sexual interest and or arousal as major symptoms. Yet, in contrast to previous formulations of disorders of absent sexual interest, the criteria for HSDD and FSIAD explicitly state that the diagnoses should not be made if “a lifelong lack of sexual desire is better explained by one’s self-identification as ‘asexual’” (DSM-5 443, 434). Thus, while the DSM-5 retains a medicalised conceptualisation of low or absent sexual desire, the reformulated exclusion criteria for HSDD and FSIAD accords a degree of legitimacy to an identity-based model of asexuality.
The periodic reformulation and/or wholescale removal of diagnostic categories from the DSM highlights how mental disorders are historically and culturally situated phenomena. Nevertheless, psychiatric science continues to privilege the search for a neurobiological and genetic aetiology of various mental health disorders. The current edition of the DSM, the DSM-5, notes for example, that “the last two decades since DSM-IV was released have seen real and durable progress in such areas as cognitive neuroscience, brain imaging, epidemiology, and genetics” in unravelling the aetiology of mental health conditions (6). Thus, while the DSM-5 cursorily highlights the relevance of socio-cultural considerations in the formulation of diagnostic categories, a great deal of scientific research in psychiatry continues to privilege causal explanations for mental disorders which are grounded in biological reductionism. Psychiatric science stresses the primacy of biology in the search for the aetiology of mental health disorders as well as the development of therapeutic modalities for such disorders. There is a tendency in fields such as neuropsychiatry, with its emphasis on MRI and other medical imagining technologies, to see “illness at the level of (increasingly microscopic) bodily processes” (Dirth and Adams 263). Furthermore, somatic therapies such as antidepressants are routinely prescribed to patients in the context of clinical practice and are indicated in the treatment of several disorders including major depressive disorder, bipolar disorder and obsessive-compulsive disorder (Michael Murphy, Ronald Cowan, Lloyd I Sederer 80). As such, psychiatric science and clinical practice constitute mental disorders as objective pathological phenomena that require medical and often psychopharmacological treatment to restore the individual patient to functional normalcy.
The medical model of disability constitutes biomedical research and treatment as the most appropriate response to apparent deficits in individual functioning and marshals economics resources towards the development of treatments and therapies that “promise to correct, eliminate, and prevent impairments that entail disabilities and their attendant restrictions on people’s life prospects” (see Tremain 86). The underlying aim of the medical model of mental disorders, then, is reforming the individual in accordance with the wider norms of the social order. Indeed, the medical model constitutes individual bodies and minds as targets for therapeutic intervention and reform, rather than social policies, economic conditions, or architectural structures (see Dirth and Adams 263). On this view, social, behavioural, or functional deviance on the part of a given individual is indicative of underlying biological deviance and abnormality.
The Social Model of Disability
As we have seen, the medical model holds that disability is situated within a given individual’s faulty biology or neurobiology; it thus positions disability as ontologically prior to social and cultural processes. That is to say, the medical model tends to constitute disability as an essential component of the neurobiology or biology of afflicted individuals. In contrast, disability studies scholarship and activism tend to place “biological determinist” accounts of disability at the forefront of critique (Erevelles 14; Thomas 143). Indeed, while not denying the ‘reality’ of material differences between bodies, disabled activists and scholars working within the field of disability studies have interrogated the notion that ‘disability’ constitutes an unmediated biological ‘reality,’ free from sociocultural determination (Erevelles 14; Thomas 143). As Colin Barnes and Geof Mercer note, the dominant theoretical model of disability within the field, namely the social model of disability, maintains a conceptual distinction between ‘impairment’ and disability (32-33). Social model theorists argue that, while ‘impairment’ constitutes a bodily or cognitive ‘reality,’ disability is not an unmediated biological ‘reality’ as such but, rather, an experience of deprivation that is brought into being by social, cultural, environmental, and institutional barriers (Barnes and Mercer 33; Barnes 2003, 49). As Colin Barnes writes, disabling barriers encountered by those diagnosed with an impairment include, but are not limited to:
[…] inaccessible education, information and communication systems, working environments, inadequate disability benefits, discriminatory health and social support services, inaccessible transport, houses and public buildings and amenities and the devaluing of disabled people through negative images of the media – films, television and newspapers (Barnes 2003, 49).
According to the understanding of disability put forward by the social model, then, a wheelchair user diagnosed with paraplegia following a spinal cord injury may be ‘impaired’ because he or she lacks lower limb function, for example. However, additional social, structural and ideational factors work to make this condition ‘disabling’ (Barnes and Mercer 33). On this view, a lack of level access provision in the workplace effectively denies wheelchair users equal opportunity for participation in the workforce. A lack of level access provision within an office environment, for example, entails that the built environment organises space in such a manner as to privilege certain bodies and marginalise others within the workplace. To the extent that the built environment excludes wheelchair users, then, from full participation in the workforce, it is effectively socially and economically disabling.
Whereas the social model has been deployed extensively in activist contexts in relation to the lives and experiences of people with physical disabilities, it has been utilised less often concerning the experiences of those within the mental health system. Nevertheless, social modelist thinking formulated by disabled people in the context of disability activism and scholarship is broadly applicable to the lives of those with psychiatric diagnoses. While an individual diagnosed with Social Anxiety Disorder might be understood to have an impairment which reduces his or her capacity to function in social situations, for example, individuals with SAD might also encounter disabling barriers in educational or professional contexts. Requiring a student diagnosed with SAD to give a presentation in front of a room full of students as part of a standard University examination might be said to constitute a disabling barrier which may negatively impact upon the students’ educational attainment. Similarly, while an individual diagnosed with Autism Spectrum Disorder might be understood to have a sensory processing impairment, public spaces such as bathrooms which incorporate stimuli that may affect sensory overload (noisy hand driers or flickering lights, for example) might be conceptualised as disabling to the extent that the design of the built environment fails to adequately take in to account human variation.
Indeed, disabling barriers are not simply architectural or environmental; they may also be institutional and systemic. Disabling barriers can be present within social care systems insofar as there is an unequal allocation (or inadequate provision) of support and the deprivation of support prohibits those with impairments from attaining an acceptable standard of living. At the time of writing, the social care crisis in the wake of the COVID-19 pandemic threatens to leave a vast number of mental health service users who require personal care and assistance without support. The Coronavirus Bill which came into effect on the 19th of March 2020 introduced several modifications to the Care Act as well as the Mental Health Act which are likely to have a severe, detrimental impact upon mental health service users. Under the Coronavirus Act legislation, local authorities will no longer be compelled to provide social care to individuals who have been identified as requiring such support under the Care Act 2014 (see Coronavirus Act 2020, Section 15 available at http://www.legislation.gov.uk/ukpga/2020/7/contents/enacted?view=plain). The emergency legislation entails that local authorities remain under a duty to provide care only in instances in which failing to meet care needs would breach individuals’ “Convention rights”, that is, Human Rights (see Section 18 of the CA). Under the emergency legislation, local authorities are advised to prioritise social care to those with the most need. The emergency legislation entails that the needs of mental health service users are likely to be deprioritised within the social care system at a time when government measures enforcing social distancing and self-isolation are likely to place a greater strain on the mental health of vulnerable individuals. Furthermore, changes to the Mental Health Act entail that patients can be now be detained involuntary with the approval of one doctor, as opposed to two (as is usually required) and for longer periods than has hitherto been permissible (see CA section 10). The changes to the Mental Health Act effectively entail there will be fewer safeguards against detention and coercive treatment of patients within the mental health system. Charity and activist organisations have raised concerns that those with the greatest mental health needs will effectively be warehoused in hospitals as opposed to given care in the community settings or within their own homes (see nsun.org, ‘Covid9: the Coronavirus Bill’).
Also, against this backdrop, Public Health England and The Department of Health and Social Care have issued guidance for the general public in dealing for with increased anxiety in the wake of the pandemic (see mentalhealth.org.uk, ‘Looking After Your Mental Health During the Coronavirus Outbreak’). A fund of five million has been allocated to mental health charities to increase the scope and provision of telephone and online support services during the pandemic (see Gov.uk, ‘Conoavirus (COVID-19): What you Need to Do’). As such, some mental health guidelines have been issued for the general public for dealing with escalating anxiety and depression as a result of the national crisis at a time when the provision of state and social support for those with longstanding mental health issues is being removed. Furthermore, even while there is an increasing acknowledgement at a state level of how social factors such as isolation, domestic confinement and deprivation of support networks may influence mental health, the state is aiming to increase psychiatric power which will enable those with mental disorders to be detained (that is confined) and segregated involuntarily in psychiatric institutions. Despite the mental health guidance issued by Public Health England which acknowledges the social determinants of mental health, then, the medical model of madness has become increasingly predominant under the COVID-19 regime insofar as there has been an increase in coercive psychiatric powers. The inadequate provision of support for those with serious mental health issues at a time when guidance about mental? is being issued for the general public constitutes an instance of state disablism (insofar as the needs of those without longstanding psychiatric histories are being prioritised over and above those with longstanding impairments).
As this brief demonstration of the social model in action reveals, the social model aims to uncover and redress systemic ableism. The social model aims to expose how the ‘medical model’ of disability, which conceptualises ‘disability’ as the outcome of an inherently ‘defective’ body or subjectivity, functions to obscure structural sources of oppression within the educational system, the economic system, the benefits system, the social care system and so on (see Tremain 9; Barnes and Mercer 28; Davis 12). Within social model scholarship, the medical model is itself reframed as a vehicle of social oppression to the extent that it consigns ‘disabled’ bodies to the category of pathology and thus naturalizes the social, cultural and political devaluation of ‘impaired’ bodies. As Julie Anderson and Lisa O’Sullivan claim, social model theorists critique the medical profession for “organizing disabled people as physically or psychologically lacking and for identifying individuals within medicine and in society more broadly, primarily — if not exclusively — in terms of their impairment or condition” (146). Insofar as the medical model defines disability as a limitation arising from a natural deficit at the level of the individual body or subjectivity, the medical model simultaneously decontextualizes disability and situates ‘disabled’ subjects outside the wider norms of the human community. As such, the social model offers a corrective to an individualized notion of disability at the heart of the medical model. Social modelist thinking effectively exposes how medical processes of individualization (the processes by which deficits are located within individual bodies) effectively elide the social and political context in which bodies are situated.
The social model of disability seeks to disrupt the hegemony of medicalised understandings of disabled subjects and expose how social processes, including (though not limited to) medicalisation, function to limit those labelled as diseased or disordered (see, for example, Oliver, 2012, 33). However, the social model has been the target of criticism by a variety of scholars within the field of critical disability studies, a newly emergent field of scholarship which draws on postmodernist thought to interrogate unquestioned assumptions about disability and ability. Critics of the social model within the field of critical disability studies claim that the binary opposition that is established between impairment and disability in traditional social modelist scholarship is unstable (Davis 13; Tremain 10). As Lennard J Davis claims, “the notion of impairment is not neutral […] but relies heavily on a medical model for the diagnosis of the impairment” (23). By defining impairment as an objectively limiting or dysfunctional property inherent to an individual body or subjectivity, then, the social model maintains, perhaps inadvertently, the logical positivism inherent in the medical model of disability. By leaving medical and psychiatric definitions of disorders, illnesses and syndromes largely unchallenged, the social model reaffirms medical and psychiatric knowledge’s apparent neutrality. As such, the social model runs the risk of reifying a biologically deterministic conceptualisation of disability which it ostensibly aims to challenge. Indeed, as Shelley Tremain argues, conceptualising impairment as a biological antecedent to socially constructed disablement fails to account for how medical diagnoses are value-laden phenomena (92). The social model, then, cannot adequately account for how medicalisation, and, more specifically the process of diagnosis which effectively determines, defines and delimits impairment, is itself a social process. As will be discussed in the following section of this blog, this presents political risks for the application of a traditional social model in the contexts of mental health policy and legislation.
The Social Model of Mental Health
Notwithstanding the philosophical inconsistencies within social modelist scholarship, the application of the social model in a mental health context presents a unique set of challenges. While, as Penson claims, the notion of an ahistorical, transcultural, objectively verifiable impairment is contestable in the context of physical impairment, it is perhaps more contestable still in the context of psychiatric impairment to the extent that there is “little clear evidence of underlying pathology in any of the functional mental health diagnoses” (61). Given that the biological causality of mental disorders cannot be clearly established, and the objectivity of diagnostic categories is contestable, mental disorders trouble the taken-for-granted dichotomy between the biological and social which is at the heart of social modelist thinking. The lack of clear evidence of a biological causality for most mental disorders entails that the various manifestations of psychiatric impairment cannot be easily conceptualised as essential, unchanging properties of certain minds (Penson 61). That is to say, mental disorders cannot be easily assimilated to a socialist model understanding of impairment which defines impairment as a static phenomenon that precedes social and cultural processes.
The socially situated nature of psychiatric impairment has led a variety of scholars, activists, and mental health service users to question the applicability of a traditional social model of disability in a mental health context. Psychiatric impairment is socially situated in a number of important ways which may engender challenges when applying a traditional social model of disability in a mental health context. Firstly, as discussed regarding asexuality and homosexuality, psychiatric diagnoses are not static phenomena; rather, they are mutable and subject to revision and reformulation in line with shifting cultural values and attitudes. Indeed, the DSM-5 constitutes behaviours and modes of affective expression which “differ from sociocultural norms” as maladaptive, suggesting that what constitutes a psychiatric disorder may, in fact, differ across diverse cultural and national contexts as well as historical periods (14). The historical contingency of psychiatric diagnoses destabilises psychiatry’s claim to objective neutrality. Indeed, mental disorders (and thus, by implication, impairments) must be conceptualised as culturally and historically relative as well as socially situated.
As noted, psychiatric impairment cannot be easily conceptualised as a fixed, essential property of certain minds that precedes the social, historical, and environmental context (that is to say, psychiatric impairments are not prediscursive phenomena). It is thus unclear to what extent psychiatric impairment might be conceptualised as ontologically prior to social processes of disablement in the context of mental disorders. Indeed, psychiatric diagnoses may themselves be conceptualised as disabling attitudinal barriers which function to discipline non-normative behaviours, lifestyles and styles of affective expression. As the historical examples of homosexuality and asexuality reveal, psychiatric labels and discourses have functioned historically to discipline and stigmatise sexual minorities. Psychiatric practice is normative, serving to reify normative cultural values and discipline those who fall beyond the remit of such values.
Indeed, within the psychiatric survivor’s movement, an activist and academic movement comprised of former service users that are critical of mainstream psychiatry, the psychiatric profession is charged with psychopathologising emotions that fall beyond the remit of cultural norms (see Tyler np). As Brigit McWade, Damian Milton and Peter Beresford note, activists “politically aligned with the psychiatric survivor movement tend to reject medical concepts of their distress and as such would not consider themselves to be psychologically impaired” (np). Psychiatric survivor literature tends to conceptualise psychiatric diagnoses as labels which legitimise social processes of discrimination, oppression and exclusion. Mad scholar David Y. F. Ho calls attention to the way psychiatric diagnoses legitimise “institutional violence” against those labelled as psychologically abnormal by authorising involuntary medical treatment and hospitalisation (3). As such, the psychiatric survivor’s movement contests perceived abuses within the psychiatric system such as the capacity for medical professionals to deprive mental patients deemed as lacking insight of the right to liberty conferred on them through the Human Rights Act (see Jacqui Dillon 156).
Similarly, activists affiliated with Mad Pride movement contend the psychiatrisation of distress and claim madness as a valid and valuable social identity, lived experience and subject position (see Tyler np). Those affiliated with the Mad Pride movement tend to be critical of processes of psychiatric normalisation which involve the use of pharmacological treatments and other therapies. Indeed, the Mad Pride movement constitutes behaviours, forms of affective expression and other non-normative experiences that are labelled as pathological (hearing voices, for example) as personally and socially valuable forms of human difference. As Ho claims, experiences labelled as pathological by the psychiatric profession may be experienced as transformative and life-enhancing rather than simply as distressing and unwanted by service users (8). Within the psychiatric survivor and Mad Pride movements, then, those labelled as psychologically abnormal or disordered by the psychiatric profession are understood as an oppressed minority group with valid experiential knowledge of madness or mental distress, rather than an aggregate of psychologically impaired individuals requiring treatment and normalisation.
As the Mad Pride and psychiatric survivor’s movement reveal, calling attention to the way psychiatric diagnoses have overlapped with broader processes of social oppression (both historically and in contemporaneity) has been an important strategy of resistance for mental health activists, self-advocacy groups and service users. As such, adopting a traditional social model of disability wholesale within the context of mental health activism is fraught with challenges. Transporting a social model of disability to a mental health context involves consigning psychiatric impairment to the realm of biological neutrality and thus forecloses the capacity to subject psychiatric diagnoses and practices to critical and ethical scrutiny. Thus, while the social model of disability has the potential to expose how systemic and structural ableism disadvantages those diagnosed with mental disorders, it effectively functions to depoliticise and dehistoricise diagnostic categories and the process of clinical diagnosis and treatment more generally. The assumed neutrality of clinical categories and processes of diagnosis is perhaps more at issue in the context of psychiatry than biomedicine. The assumed neutrality of psychiatric diagnoses is at issue for service users due in part due to the capacity for psychiatric professionals to deprive those defined as disordered of liberty and other human rights accorded to normative individuals (there is a potential for detaining mental patients in hospitals involuntarily under the Mental Health Act, for example). Given these and other challenges, scholars within the field of mad studies have advocated reformulating the social model of disability for use in mental health contexts (see Penson 64; Peter Beresford, Mary Nettle and Rebecca Perring 7-8).
More specifically, scholars within the field of mad studies have suggested that an essentialist concept of impairment requires reformulation if the social model if to be effective as a tool for generating change within the mental health system (see Peter Beresford, Mary Nettle and Rebecca Perring 8). Several scholars have explored the relationship between psychological impairment and psychological distress in the interest of advancing a social model of mental disorders (see Jerry Tew 20). Psychological impairment might be conceptualised as an outcome of social-psychological distress which environmentally, relationally, and economically determined. As Jerry Tew claims, the social model of madness might “explore the ways in which mental distress may be understood as, in part, a response to problematic life experiences” such as abuse, trauma and oppression (20). Tew suggests psychological impairment might be conceptualised in terms of a dysfunctional “acting out” of previous traumatic or abusive experiences or as a “survival strategy” that “a person may be using in order to deal with particular painful or stressful experiences” (20). Within this framework, mental disorders constitute a constellation of dysfunctional behaviours and modes of affective expression that may assist an individual in dealing with adverse life experiences but nevertheless be maintained at personal cost to the individual as well as others around them (Tew 20). Tew’s socially situated conception of mental distress productively undermines an essentialist, biologically determined notion of psychiatric impairment that underlies the medical model of mental disorders.
However, while the role of trauma and abuse in mental distress should not be underestimated, neither should the role of structural sources of oppression be elided. An emphasis on domestic or familial factors underlying mental distress to the exclusion of structural sources of oppression in psychiatric literature tends to individualise mental disorders and elide the extent to which racism, economic inequality, sexism, homophobia, transphobia and ableism and other forms of social inequality are generative of psychological distress. Indeed, a report compiled by the World Health Organisation highlights mental health correlates highly with one’s social position (Frideli iii). As Lynne Friedli claims, dysfunctional or otherwise harmful behaviours may be coping mechanisms adopted by individuals “in the face of multiple problems, anger and despair related to occupational insecurity, poverty, debt, poor housing, exclusion and other indicators of low status” (iii). Friedli’s text highlights how ‘individual’ psychology is socially situated. This is to say, despite the dominant discourses of personal responsibility within psychiatric literature, mental distress or health is produced in both context and practice. As Frideli goes on to state “mental health is produced socially: there presence or absence of mental health is above all a social indicator” (V). Furthermore, to the extent that these systems of oppression are largely beyond an individual’s capacity to intervene or alter (at least in the short to medium term), it is unclear to what extent psychological distress constitutes a dysfunctional or maladaptive response on the part of a given individual to an abnormal set of social conditions. Rather, psychological distress might be understood as a necessary or adaptive response to a difficult or aversive set of social conditions. Indeed, as Frideli claims, while associated with mental health “‘happiness’, ‘positive thinking’ and ‘trust’ are not always adaptive responses” (V).
Furthermore, the social model of mental distress as it is formulated by Tew retains a notion of mental distress as ontologically problematic – that is to say, as essentially ‘bad.’ Indeed, while Tew’s formulation of psychiatric impairment is sensitive to the social determinants of mental health, it is at odds with the way mental distress has been conceptualised within user-led movements such as the Mad Pride and Psychiatric Survivor’s movements. The notion of mental distress as ontologically problematic is contestable. As Fridell claims, while there is an established and clear association between positive affect and wellbeing “this is not the case for residents of institutions; in these circumstances, low positive affect ‘may reflect a fighting spirit in a situation of lost control’ and so be more protective” (19). The finding that negative affect may be beneficial in the context of institutionalisation contests the medical assumption that mental distress is essentially or inevitably maladaptive across all social circumstances.
Applying a traditional social model of disability in the context of mental health has the potential to expose how disabling barriers delimit the life prospects of those diagnosed with mental disorders and facilitate the development of more equitable mental health legislation and policy. However, retaining a social modelist notion of impairment as a biological given functions to elide the extent to which psychological impairment might be understood as a social phenomenon: a response to longstanding mental distress that arises in relation to a disadvantageous set of social conditions. Furthermore, theoretically bracketing off psychiatric impairment as a biological given precludes the capacity for activists to fully address abuses in the psychiatric system that coalesce around the process of clinical diagnoses and treatment. Recognising that mental impairment, and not simply mental disability, constitutes a socially situated phenomenon requires reformulating the social model for application within a mental health context (see Penson 60). A number of activists and scholars within the field of mad studies have suggested there may be a need to navigate away from a social modelist notion of impairment as natural and inevitable if the social model is to be effective as a theoretical tool for transforming mental health services, policy and legislation. As Penson suggests, psychiatric impairment might be understood as a socially situated and relational phenomenon (60).
Indeed, reconceptualising impairment as socially situated may be a necessary step for mental health activism and scholarship, particularly given that social inequality has been identified as a key determinant for mental distress. As Frideli highlights, given that “an extensive body of research confirms the relationship between inequality and poor [mental health] outcomes”, more equitable social and economic conditions are needed to engender better mental health for a greater number of people (III). Fideli’s WHO report highlights how affective resources are unevenly spread across the social sphere since individuals within a given population do not have equal access to social, economic, and material resources. More than simply better mental health services and more equitable mental health legislation and policy, then, better mental health for greater numbers of the people requires structural transformation at all levels of society.
Ellena Deeley is PhD candidate at the University of Exeter. Her thesis explores representations of conjoined twins in contemporary literature and screen media.
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