Transcript Insight in mental illness and individualisation

Insight in mental illness and
individualisation
John Aggergaard Larsen
European Institute of Health and Medical Sciences,
University of Surrey
Email: [email protected]
Paper presented at the symposium ‘Sociology of
Mental Health: Continuity or Change?’, BSA Annual
Conference, 21-23 April 2006, Harrogate
Aims of paper
• To argue that contemporary mental health treatment
celebrates biomedical notions that ‘essentialise’
mental illness in the person and reflect
individualisation in society
• To argue that this ideology is presented and taught
(‘socialised’) through complex sociocultural
processes that require the critical attention of a
sociology of mental health
• To invite debate over the future empirical and
theoretical investigation of these macro and micro
processes – and their interplay
Trends in contemporary
mental health treatment
• Increased use of effective psychoactive medication
(e.g. antidepressives, atypical antipsychotics)
• Increased general popularity of ‘talking cure’ –
‘therapy culture’ (e.g. Furedi 2004)
• Psychiatric awareness of need for holistic/integrated/complex ‘biopsychosocial’ interventions to help
people learn to ‘live with’ difficulties – ‘recovery
model’ (e.g. mental health outreach teams and early
intervention in psychosis services)
• Dominance of biomedical and psychiatric diagnostic
language in mental health practice (e.g. Barrett 1996;
Luhrmann 2000)
Empirical illustration of claims:
Person-centred ethnographic study of early intervention
in psychosis service in Copenhagen, Denmark
• 2 years fieldwork over a 3.5 year period (1998-2001)
in active membership role as project evaluator
• Participant observation with staff and in therapeutic
groups
• Multi-method approach to illuminate perspectives of
staff, clients and relatives: individual interviews, focus
groups, attitude surveys, registration forms, written
narratives
• Repeated interviews with 15 clients over a 2.5 year
period – and creative-expressive collaboration in
book project
(Larsen 2002, 2003, n.d.a; Sharkey and Larsen 2005)
The early intervention in
psychosis service
• Early intervention in psychosis for young people (1835 years old) in Copenhagen – OPUS
• Diagnosed within the ‘schizophrenic spectrum’ (ICD10)
• Two-year intensive ‘bio-psycho-social’ community
outreach treatment and support through: low dose
‘atypical’ medication, case manager, family groups
and social skills training
• Cognitive behavioural therapeutic (CBT) approach
• Focus on social rehabilitation
Therapeutic work focused on
psychoeducation and cognitive
behavioural therapy (CBT) to help clients:
•
•
•
•
gain ‘insight in illness’;
take their medication correctly (‘comply with’);
identify symptoms and respond appropriately;
learn and train social skills to be ‘well-functioning’
(velfungerende);
• communicate with their families appropriately (low
‘expressed emotion’, EE) to strengthen social
network considering client’s mental illness and,
hence, reducing stress and minimising risk of
relapse;
• help with living: financial support, housing, education,
job – negotiate social welfare services
‘Insight in illness’: medicalising
and essentialising mental illness
• Clients initially were sceptical about taking
psychoactive medication – taking medication meant
‘being ill’
• Over time, and due to therapeutic work in service,
clients came to accept taking medication and ‘being
ill’ – focus shifted to a concern with not feeling ill or
‘becoming ill’ (medication as ‘“vitamin pills” to
regulate the biochemical balance in the brain’).
• The shift from an essential to an experiential
understanding of mental illness involved a notion of
mental illness as an alien within the self and
medication allowed to ‘be myself’
Therapeutic processes and
the person
• Biomedical and ‘cognitive deficit’ notions of mental
illness dominated the ‘symbolic healing’ provided in
the service (Larsen n.d.b)
• These explanations provided the individual with an
identity as ‘mentally ill’ – and suggested revision of
self-perception and life plans (Larsen 2005)
• Some clients found these explanations unsatisfying
and sought alternative systems of explanation from
the wider cultural repertoire in creative work of
bricolage (Larsen 2004)
The individualisation of
mental illness and health?
• The mental illness is individualised – or perhaps ‘subindividualised’ – as agency and individual responsibility is
seen as external to the illness that ‘works within’
• Mental health and illness is becoming a question of
accessing and applying expert knowledge to manage and
control symptoms
• Recovery is a continuous process (of controlling and
managing) rather than a resolution (becoming ‘healthy’)
• In this situation, is individual agency less a question of
‘freedom to act’ than a struggle to obtain and apply expert
knowledge to seek to moderate and manage systems and
processes ultimately beyond our control?
Towards a critical social science
of mental health and treatment
• Critically investigate the sociocultural processes involved
in therapeutic work:
– what is it that makes them therapeutically effective?
– how are new social roles, identities and self-perceptions
created?
• How do individuals (patients/clients) experience and
respond to and challenge these interventions?
• How does the therapeutic ideology and practice relate to
wider societal processes such as the market-driven
pharmaceutical industry; funding arrangements for mental
health treatment; training and practice development in
mental health practice; notions of the person and the
‘well-functioning’ individual
References
Barrett, Robert J. (1996) The Psychiatric Team and the Social Definition of Schizophrenia: An
Anthropological Study of Person and Illness, London: Cambridge University Press.
Furedi, Frank (2004) Therapy culture: cultivating vulnerability in an uncertain age. London and
New York: Routledge.
Larsen, John Aggergaard (2002) Experiences with early intervention in schizophrenia: An
ethnographic study of assertive community treatment in Denmark, PhD thesis, Department
of Sociological Studies, University of Sheffield.
Larsen, John Aggergaard (2003) ‘Identiteten: Dialog om forandring’ [Identity: Dialogue on
change], In K. Hastrup (ed.) Ind i verden: En grundbog i antropologisk metode, pp. 247-271.
Copenhagen: Hans Reitzels Forlag.
Larsen, John Aggergaard (2004) ‘Finding meaning in first episode psychosis: Experience,
agency, and the cultural repertoire’, Medical Anthropology Quarterly 18(4): 447-471. web
link
Larsen, John Aggergaard (2005) ‘Becoming mentally ill: Existential crisis and the social
negotiation of identity’, In V. Steffen, R. Jenkins, and H. Jessen (eds.) Managing uncertainty:
Ethnographic studies of illness, risk and the struggle for control, pp. 197-223. Copenhagen:
Museum Tusculanum Press. web link
Larsen, John Aggergaard (n.d.a) Understanding a complex intervention: person-centred
ethnography in early psychosis, unpublished manuscript.
Larsen, John Aggergaard (n.d.b) Symbolic healing of early psychosis: psychoeducation and
sociocultural processes of recovery, unpublished manuscript.
Luhrmann, Tanya M. (2000) Of Two Minds: The Growing Disorder in American Psychiatry, New
York: Alfred A. Knopf.
Sharkey, Siobhan and John Aggergaard Larsen (2005) ‘Ethnographic exploration: Participation
and meaning in everyday life’, In I. Holloway (ed.) Qualitative Research in Health Care, pp.
168-190. Maidenhead: Open University Press.