Transcript Sociology, culture and psychiatry

Sociology, Culture and
Psychiatry
Dr Alex Hunt
Clinical Psychologist
Conceptions of Mental Health
• Psychiatric
• Biomedical model – mental illness approach
• developed from physical medicine
• Psychoanalytic
• Conflicts
• Deficits
• Psychological
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Statistical notion
Ideal notion
Presence or absence of specific behaviours
Distorted cognitions
Conceptions of Mental Health
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Social causation
Critical theory
Social constructivism (constructionism)
Critical realism
(medical) anthropology
Conceptions of Mental Health
• Lay conceptions
• Lay conceptions and psychiatrics labels concur (in
western societies)
• Mental health viewed along a continuum – up to a point
– Some mental health problems viewed as normal experience
‘stress’ ‘depression’
– More severe mental health problems viewed differently – based
upon stereotype
Stigma
• Stigma a form of stereotype
– The tendency for human beings to attribute fixed
and common characteristics to whole social
groups
• Stereotype to stigma
– Prejudicial social typing
– Emotion reaction
– Moral reaction
Stigma
• Elements involved in defining and stereotyping
mental illness:
• Dangerousness
• Intelligibility
– How intelligible is person behaviour – has to make sense
within the current context
• Competence
– Creativity
– Obsessionality
– Religion
Conception of mental health
Bad
Abnormal
Normal
Mad
Labelling Theory (Scheff, 1966)
• Positive effects – access to treatment /
normalising
• Negative effects – hierarchy of stigma
mentally ill are disvalued, below prostitution,
epilepsy and alcoholism
• Modified labelling theory (Link & Phelan,
1999)
– – social rejection based upon shared cultural
assumption about mental illness.
Response to Stigma
• Information control
– Unlikely to be discovered conceal
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Compensate
Exaggerate (generalise)
Pass, get by
Switch styles
Role of Mass Media
• Media on the whole supports and strengthens
stereotype
– Violence, otherness,
– Don’t concur with psychiatric descriptions
– Pathetic dependence or silliness
• Humane biographical accounts (films,
documentaries)
Social Exclusion
• Societal discrimination –
• Rights can be suspended –compulsory
detention and involuntary treatment
• Poorer housing
• Less chance of employment
– Psychosis 1 in 4
• poverty
• Less likely to be involved / included in
community
Stigma
• Discrimination for people with mental health
difficulties high (social exclusion unit)
• ONS
– positive attitudes about mental illness deceased
– Fear of mental health users increased
– Tolerance of people with MH problems
decreased
Anti Stigma
• Anti-stigma (discriminatory) campaigns
• RCPsych
– Changing minds – mental illness is an illness like
any other illness
– Biological not persons fault
• User movement
– Psychological – oppression and social causes
Social Class & Mental Health
• Black report
– Lower SES associated with greater morbidity and
mortality
• Mental health – poverty and mental health
• Affective disorders diagnosed evenly across
social classes
• Strong correlation between low SES and
schizophrenia
Relationship Between SES and MH
• Social drift theory
• Life events
– Greater negative life events in low SES
• Social causation
– Material deprivation
– Less access to resources
– Poorer environment
– Health behaviour
MH and Employment
• Better prognosis for those diagnosed with
psychosis who are employed
• Work factor in depression
– relationship between anxiety and depression and
SES dependent on employment status
– Unemployed men more likely to have MH
problems than unemployed women
Sick Role & Illness Behaviour
• Sick role – sanctioned deviance, Policed by
medical profession
Exit sick role
(get better)
Becoming ill
SICK!
Chronic
condition
corpse
Medical
profession
Sick Role
• Talcott Parsons (1951)
• Contract with rules:
– Rights:
• The sick person is exempt from normal social roles
• The sick person is not responsible for their condition
– Obligations:
• The sick person should try to get well
• The sick person should seek technically competent help
and cooperate with the medical professional
Sick Roles
• Variety of sick roles culturally
– Baby
– Corpse role
– Angry
– Scapegoat
– Sometimes not allowed any
Sick Roles
Patient as sacred
“Baby”
“Angry”
Passive
Active
Acute
Chronic
“Corpse”
“Scapegoated”
Patient as shameful
Gender & MH
• Some diagnoses not gendered, schizophrenia and bi-polar
• Some inevitably limited to women
– Post-natal and post partum psychosis
• Overwhelmingly female
– Anorexia & bulimia
– BPD
• Overwhelmingly male
– antisocial personality disorder
– Sex offenders
• Substance misuse more likely in men
• Anxiety and depression more likely in women
• Dementia (women live longer)
Over–representation of Women
• Society causes excessive ‘mental illness’
– Increased social demands and lack of structure
– Entrapment and humiliation
• Increased vulnerability – adverse childhood
events –CSA, rape
• Measurement artefact
– Research tools
– Help seeking
Women and Mental Health
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Labelling theory
– Feminist influence
– Women labelled more often than men
– GP’s more likely to label psychological problems
in women than men
– Sexism in psychiatry
– Medicalisation of female experience
– The great tranqulizer debate
Men & Mental Health
• Men are viewed as more dangerous – weak
stereotype
• Men over represented in prison, women in
mental health population – social judgements
• Gender expectations –
– Externalising vs internalising
Culture & Mental Health
• How universal are psychiatric diagnoses?
– Historical context
– NY vs London
– Categorisation
• WHO study
– Cross culturally something approximating
schizophrenia in each country (this can be
debated)
– Prognosis, better level of care and input = better
outcomes? NO!
Culture and Mental health
• Two parts
– The symptoms
– Social responses to the symptons – social process
• Western medicalised – internalised –internal
stable attribution….controllable?
• Developing – spirit possession – external,
unstable explanation….uncontrollable?
Culture and Mental Health
• Emic vs etic approaches
• Culture bound syndromes
– Category fallacy?
– Cultures undeveloped
– Variant of western diagnoses?
Culture and Category
Personalistic
Variation in presentation of
symptoms / epidemiology across
cultures
Anorexia & Bulimia
Amok
Latah
Depression
“psychosis”
Biological
Social
Hypothesised influence on presentation
Cultural
Ethnicity and Mental health
• Different ethnicities over represented in
psychiatric populations
• Irish and Afro-Caribbean over represented
why not others?
– Genetics
– Migration
– Racism
• Cultural explanations – belonging /
fragmentation