Mental Health Example #2 Essay
‘Mistreatment and oppression is the common lot of people in our societies who are labelled as having emotional problems or acting irrationally. The threat of being called crazy is used in the oppression of every group in the population. The oppression of some people in the name of mental health functions as a threat to keep all people in line. ‘
The above quote suggests that the experience of being diagnosed or labelled as having mental health problems, whether officially by professionals, or unofficially by lay people, family members and others with whom we have contact, is not only used as a means to explain a persons difficulties, but also as a means of control. In this instance that control is achieved through the widespread use of fear.
That fear is founded on the stigma and discrimination that people with mental health problems experience on a daily basis and only works as a means of control if everyone in society is aware of the prejudicial treatment with which they themselves treat other people. This work will examine the control of persons labelled as ‘crazy’, historically, politically and socially. It will raise questions concerning definitions of mental health and ask whether such labels are being applied to people whose behaviour does not fit with the hegemonic standards of morality that exist in society at a particular point in time.
We will also be looking at the experiences of young people using Nightstop, a voluntary sector project, and seek to show how homeless young people are at a greater than average risk of developing mental health difficulties whist suggesting practical steps that can be taken to reduce that risk. Definitions of mental ill-health have fluctuated over time and place and they are inextricably bound up in social and cultural norms. Graham Richards also argues that a society’s concept of madness is necessarily also a statement of normality (although each eludes neat formulation).
The boundary defines both sides and, to be meaningful, sanity needs a counter-concept of madness’ (Richards, 1996:77). This points to a need for a definition of mental wellness as well as one of mental illness. Ann Hagel wrote that mental wellness could be seen to imply ‘stability and balance, reasonable self esteem, feelings of competence, and the ability to meet successfully the demands of a range of roles in which an individual operates. (Hagel in Clarke, Module Reader, 2003:14)
She defines mental illness as an imbalance and an inability on the part of the person to ‘perform their social roles’ (Hagel in Clarke, Module Reader, 2003:14). Whilst discussions around emotions and feelings concern the internal world of the person, issues around performance of social roles are concerned with the external world and acceptable behaviour. Both are used as definers of mental illness. The manifestation of mental illness in behavioural terms can be seen in the law courts.
In legal terms questions of whether a defendant is ‘mad’ or ‘bad’ are frequently sited in deciding responsibility for and promoting an understanding of criminal behaviour. Pilgrim and Rogers point out that mental illness has no medical definition in criminal law and they note a case in 1974 where the judge quoted Lord Reid as saying ‘I ask myself what would the ordinary sensible person have said about the patient’s condition in this case if he had been informed of his behaviour? In my judgement such a person would have said ‘Well the fellow is obviously mentally ill’ (Pilgrim and Rogers, 2002:10).
Graham Richards questions the link between mental illness and behaviour and claims that ‘behaviours judged as socially unacceptable (are) being medically objectified as mental illness. ‘ (Richards, 1996:82). Likewise Thomas Szasz raised issues of behaviour but he also questioned the terminology of mental illness. ‘Mental illness is a metaphor (metaphorical disease). The word “disease” denotes a demonstrable biological process that affects the bodies of living organisms (plants, animals, and humans).
The term “mental illness” refers to the undesirable thoughts, feelings, and behaviors of persons. Classifying thoughts, feelings, and behaviors as diseases is a logical and semantic error, like classifying the whale as a fish. ‘ (Szasz, 1998:www. szasz. com/manifesto). But whether or not mental distress is an illness and whether or not that illness has a psychological or biological basis, Szasz argues that ‘the classification of (mis)behavior as illness provides an ideological justification for state-sponsored social control as medical treatment’ Szasz, 1998:www. szasz. com/manifesto).
Ascribing definitions of mental illness to behaviour had its origins in the 18th and 19th century and the advent of behaviourist psychology and as Pilgrim and Rogers argue whilst this achieves clarity in terms of what is acceptable and what is not, it is clearly based on the values and norms operating at a particular time and place, as decided by those in power. ‘Those who have more power will tend to be the definers of reality. Thus what constitutes unwanted behaviour is not self evident but socially negotiated.
Consequently it reflects both the power relationships and the value system operating in a culture at a point in time. ‘ (Pilgrim ; Rogers, 1999:10). Definitions of mental illness are not therefore stable and unchangeable. As Graham Richards puts it ‘society as a whole, not just doctors, decides on what should count as ‘normal’ behaviour. And society is forever changing its mind. ‘ (Richards,1996:84).
Historically the link between acceptable behaviour and definitions of mental illness can be seen in the work of writers such Pritchard who in 1835 wrote of mental illness, The moral principles of the mind are strongly perverted or depraved; the power of self government is lost or greatly impaired and the individual is found to be incapable not of talking or reasoning upon any subject proposed to him, but of conducting himself with decency and propriety in the business of life’ (Pritchard in Pilgrim and Rogers, 2002:168). This is not a definition that speaks of problems concerning emotional distress, rather it is a definition based on behaviour. It is also indicative of a growing 19th century trend to associate mental illness with a lack of moral standards.
It is interesting to note that Pritchard does not attribute mental illness to difficulties in reasoning which suggests a belief in a purely physical dimension of mental illness which can also be seen in debates at the time around tainted gene theory and concerns about inbreeding which were put forward to explain what they saw as the undesirable and amoral behaviour of the lower classes.
Writing of the use of asylums in the treatment of mental illness David Jones suggests that whilst asylums in the 18th and 19th century were allegedly places where people could be cared for, there is a second, critical account (which) sees the asylums as emerging from increasingly sophisticated systems of classifying and controlling various forms of deviance. – asylums were part of the same system as the workhouse and prison, they were places where those whose behaviours threatened the social order could be gathered together and controlled. ‘ (Jones, 2002:11). Jones also argues that families were active players in this process since families used asylums to place family members with whom they had difficulties, ‘families were – involved in the very identification of mental illness’ (Jones, 2002:7).
Families in the 19th Century were seen as the arena within which society ‘could instil discipline into growing children and could enforce responsible behaviour onto the parents. ‘ (Jones, 2002:13). Insanity was therefore the result of the family’s failure to fulfil these roles and was seen as justification for removing people and placing them in institutions that could ‘provide a setting in which people could learn a self-regulating discipline’ (Jones, 2002:14).
Families were clearly held accountable for the mental illness and lack of acceptable behaviour of their relatives whether this was seen as a result of genetic inferiority or the failure of women to adhere to their mothering role within the family they were clearly identified as the source mental illness. This continued into the 20th century when the Tavistock Clinic (1914) became associated with an emphasis on family by ‘promoting explanations of delinquency and the mental distress which were purported to arise from poor mothering’ (Pilgrim & Rogers, 2002:110).
In 1958 Nathan Ackerman, a leading proponent of the family therapy movement, stated that ‘blatantly in evidence are the disorganising trends in contemporary family life, the conflicts and failures of complementary in man-wife relations, the signs of disintegration of the moral and ethical core of family relationships’ (Jones, 2002:19). This was fairly typical of the family therapy movement that actively sought explanations of mental illness within the families of sufferers.
In 1964 R D Laing said to the best of my knowledge, no schizophrenic has been studied whose disturbed pattern of communication has not been shown to be a reflection of and reaction to the disturbed and disturbing pattern characterising his or her family of origin’ (Laing in Clarke, 2003: Module Reader:11). In 1996 McKay et al reported that ‘deviant family values have all been linked to the emergence of behaviour difficulties in urban adolescents’ (McKay in Clarke, 2003: reading 34:16) and they asserted that family factors have been consistently implicated in studies of aggressive behaviours and appear to be among the most powerful predictors of risk’ (McKay in Clarke, 2003: reading 34:16).
Blaming families for the mental illness of their relatives serves two distinct purposes. Firstly it places the causes of mental illness within the ‘private’ realm of the family and secondly it allows for policy makers abdication of responsibility by clouding other issues such as poverty, unemployment, race and homelessness in discussions concerning the causes of mental illness.
In The Health of the Nation (DOH 1992) document there is a significant absence of issues relating to poverty something Buck points out. ‘Attention to significant findings concerning associations between poverty, unemployment and mental ill health have been omitted, implicitly acknowledging the governments abdication of responsibility for these areas’ (Buck in Clarke, 2003: reading 13). Unfortunately, families have also been implicated in the cause of poverty and unemployment, again for not instilling in their children the willingness to work and support themselves.
Peter Lilley, Social Security Secretary in 1992, stated that ‘poverty is the result of people’s idleness. Some people do not want to work, they are simply scroungers’ (Buck in Clarke, 2003: reading 13). Thatcher’s government were strong proponents of the family as a means of preventing dependence on the welfare state. They saw the break up of the traditional family as having negative effects on society in general and as being responsible for the increasing demands being made on an already over burdened welfare state.
They created an array of social policies that sought to reinstate the nuclear family (biological parents living together and raising their biological children) and encourage families to depend on themselves for welfare. Butterworth argues that this was nothing less than ‘a form of social engineering – that aimed to restore the traditional/nuclear family by trying to ensure for example that the male breadwinners were breadwinners and not dependent on benefits’ (Butterworth, www. socialissues. co. uk/articles/article1)
The development of Community Care policies have been seen by many to indicate a commitment to this ideological stance that seeks to ‘resource and strengthen the family in order that they can care for their ‘own’ dependents’ (Jones, 2002:17) (this would include family members dependent by virtue of their mental health) and thus reduce the burden on the welfare state. Blaming the family for causing mental illness and subsequently demanding that families take responsibility for the care of those with mental illness places great demands on familial relationships that can and do lead to conflict and separation.
Many young people at Nightstop that have been evicted by the family are described by them as being mentally ill and/or behaving in unacceptable ways that suggest that ‘they are not normal’ (clients mother) which then serves as justification for eviction. In some ways this is reminiscent of the use families made of asylums in the 19th century but as these no longer exist and as families report great difficulty in persuading the medical profession to recognise their children’s mental health difficulties, they cannot access hospital services. They therefore reach a point where they cannot cope and put them out of the family home.
What is interesting to note in this is that families are also identifying behaviour as indicative of mental illness and they are still actively involved in diagnosing same. The family is therefore an important player in discussions concerning definitions of mental illness, the causes of mental illness and the treatment and rehabilitation of those labelled as mentally ill. Definitions of appropriate behaviour have also had their origins in ideological assumptions about ‘the family’ and definitions of mental illness have oft times been based on a persons ability to conform to and perform acceptable familial roles.
Pilgrim ; Rogers pick up on this point when looking at the over representation of women within mental health services as they offer a view point that suggests ‘patriarchal authority which seeks out and labels women as mad, is responsible for the over representation. Women become vulnerable to being labelled mentally disordered when they fail to conform to stereotypical gender roles as mothers, housewives etc. , if they are too submissive, too aggressive or hostile to men’ (Pilgrim ; Rogers, 1999:31).
The fact that homosexuality was only declassified as a psychiatric illness by the World Health Organisation in 1992 offers another possibility of how failure to conform to acceptable familial roles can lead to labels of mental illness. The identification of different familial organisation within minority groups has not been excluded from attack in respect of mental illness and differences between such families and the traditional, white, British, nuclear family have been highlighted for special attention.
What we are left with is a belief in the failure of the family as a cause of mental illness and a clear identification of diagnosis resting with unacceptable behaviour. Both of these standpoints serve the interests of different sections of society. In blaming the family we see the possibility of abdication of responsibility, and in the control of unacceptable behaviour, we not only have the ability to remove people whom we believe represent a threat to our ideas of social order, but the treatment of said undesirables actually provides an excellent opportunity to make money.
This is not only in terms of the services of professionals such psychiatrists and psychoanalysts and all of those who make a living from mental health services but also in terms of the profits to be made from the provision of drugs. The use of drugs, like the blaming of the family clouds the debate concerning the causes of mental illness and ‘the treatment of individual ‘pathology’ disguises its social causes and deflects attention from the need for political change’ (Pilgrim ; Rogers, 1999: 35).
The use of prescription drugs is itself a form of social control since ‘they transform social problems into medical ones’ (Pilgrim ; Rogers, 1999:35) and in terms of the control of unacceptable behaviour drugs are particularly suited to the purpose ‘because they can be imposed in the absence of co-operation’ (Pilgrim ; Rogers, 2002:123). Taking drugs once prescribed also takes on an issue of control and lack of choice since the failure to take such drugs is used as evidence of further mental health problems and leads to many admissions to psychiatric hospital where treatment can be imposed.
This is despite the fact that the side effects can have a devastating effect on recipients and further reduce their ability to take part in every day life. In the case of the anti-depressant Seroxat these have included a reported increase or manifestation of aggressive behaviour. Unfortunately some of the people responsible for monitoring the side effects of drugs are also involved in the production of same and they dismiss patient reports as ‘unscientific’ (Panorama, 11th May 2003).
Drugs are also cheaper than talking therapies and again there is a vested interest in sustaining their use since they support the biological model of mental illness. And ‘if such a position is not persuasive, then arguably mental illness is actually a sort of social, education or existential, not physical problem’ (Pilgrim ; Rogers, 2002:122) which would raise questions of responsibility for social change. Here we have a clear case of oppression where the lack of power on the part of people labelled as mentally ill is extreme and any attempt by them to exercise power and demand choice, is dismissed as further evidence of their illness.
Pilgrim and Rogers argue that ‘Mental illness is about a flawed or deviant self. This is why a psychiatric diagnosis has such profound implications, as a patients credibility as a social actor or citizen is questioned, possibly for life’ (Pilgrim ; Rogers, 2002:17) But not only do people with mental health difficulties have to deal with definitions of mental illness that label them as undesirable, their behaviour unacceptable, their experiences invalid and their families to blame, they also have to deal with their own feelings about who they are.
David Jones argues that stigma is not only the result of the perception of others but is also attached to feelings of shame that are ‘the result of a discrepancy between their perception of their actual selves and their vision of their ideal self’ (Jones, 2002:97). He argues further that ‘shame is about being in the world as an undesirable self, a self one does not wish to be’ (Jones, 2002:98).
Both however are the result of interactions with others since ‘it is through dialogue with others that we reach a better understanding of ourselves’ (Jones, 2002:136) which concurs with Charles Taylor’s work on the construction of self where value and meaning are derived from our ability to construct stories about ourselves, in which we can orientate ourselves within the moral narratives that we find around us’ (Jones, 2002:151). Stigma and discrimination therefore compound feelings of worthlessness and effectively silence the witnesses to oppressive practices. What is significant about this for youth and community workers is that all of the above can be applied to the experiences of young people regardless of their mental well being.
When such experiences are also linked to questions concerning their mental health then young people are particularly vulnerable to the control functions of society such as the police, social services and psychiatric treatment. At Nightstop this is compounded further by the fact that the young people with whom we work are also homeless. Homelessness itself has been identified as a cause of mental illness although the debate is fairly circulatory since it questions whether people with mental health problems are more likely to end up homeless as opposed to experiences of homelessness causing mental distress.
However, young homeless people appear to be at increased risk of developing mental health problems if we look at the risk and resilience debate about mental illness. ChildRight argues that risk factors are those that increase the risk of someone developing mental illness and that they are cumulative in that the greater number of risk factors present, the greater the likelihood of mental illness developing.
They identify several such factors, child risk factors that include issues around academic failure and self esteem, environmental risk factors such as homelessness, poverty, disaster and discrimination and family risk factors which include Overt parent conflict; family breakdown; inconsistent or unclear discipline; hostile and rejecting relationship; failure to adapt to a child’s changing needs; physical, sexual and/or emotional abuse; parental psychiatric illness; parental criminality; alcoholism or personality disorder and death and loss (including loss of friendship)’ (Kay in Clarke, 2003: reading 14:153). The majority of young people we see have become homeless as a result of family difficulties.
Some young people feel they had no choice but to leave and they give abuse as a reason for this. Many have been forcibly evicted from the family home which is the result of family conflict, breakdown and rejection and as mentioned earlier this is often tied up in definitions of them as unacceptable. As young people they are not entitled to full benefits and social policy dictates that they are restricted to single room rent in terms of housing benefit. They are therefore at a distinctly lower income than adults (aged 25 and over) when they are unemployed.
Young people are also excluded from guidelines concerning minimum wage entitlements and again when they are old enough to be eligible the rates are lower, which means that when employed they are likely to be in the lower wage bracket. All young people we work with have experienced loss, sometimes this is through bereavement but all have lost their home, often family contact and subsequently many friendships. The youngest age group have usually had their education severely disrupted by homelessness and tend to view this as failure. Their self esteem is often understandably low.
Their risk factors are therefore extreme. ChildRight also identify several resilience factors which help protect young people from the full extent of risk. These include personality traits such as a sense of humour and intelligence and skill based abilities such as good communication, problem solving and reflective abilities, family factors such as at least one good parental relationship and supportive factors and they also identify community based factors such as good housing, a high standard of living and the opportunity to participate in social and leisure activities.
Whilst most of the young people we work with have a wonderful sense of humour, they do not always have the skill based abilities identified. Family factors are usually a source of conflict not support, access to social and leisure activities is limited by income whilst housing or the lack thereof is their main issue. They do not therefore have an adequate stock of protective factors. Homeless young people are therefore at a greater than average risk of developing mental health problems and this is reflected in the large numbers of young people we see that already have mental health difficulties.
Again this risk is visible if we discuss issues around competence. Many definitions of mental health talk of competence. Ann Hagel touches on this when in her definition of mental health she talks of ‘feelings of competence, and the ability to meet successfully the demands of a range of roles in which an individual operates. ‘ (Hagel in Clarke, Module Reader, 2003:14). Kay suggests that ‘all too often insufficient attention is paid to emotional well being and competency with serious consequences for young people’s mental health. ‘ (Kay in Clarke, 2003: reading 14:154).
Albee develops this further by offering suggestions for intervention designed to reduce the incidence of mental illness in young people by ‘increasing the competence of young people to deal with life’s problems, particularly with the problems of social interactions and the development of a wide range of coping skills. In this area, a great deal of recent research indicates that young people can be taught a variety of social and cognitive skills that increase their ability to deal with the problems of living and which, as a consequence, reduce the incidence of frustration and emotional disturbance’ (Albee in Clarke, 2003: reading 26:1047).
This is particularly relevant in our work with homeless young people many of whom are thrust into the adult world of responsibility long before they are ready and who, as a result, lack many of the competences necessary for independent living. These are not only the practical skills of budgeting, shopping and cooking but also the emotional skills involved in dealing with the ‘increasingly complex worlds of work and relationships’ (Kay in Clarke, 2003: reading 14:154).
Competence, or feelings of competence are also linked to issues of self esteem which is described by Nathanial Brandon as ‘the disposition to experience oneself as competent to cope with the challenges of life and as deserving of happiness’ (Brandon in Alexander in Clarke, 2003: reading 32:2) and by Alexander as ‘a profound reality which provides insights into how to live well and treat others so that we all live well’ (Alexander in Clarke, 2003: reading 32:4).
Unfortunately issues of self esteem and competence are undermined by the political position of young people in current society. Political parties are almost unanimous in their patriarchal attitudes that suggest young people need stronger discipline, more control and increased adult supervision. This coupled with the assumed incompetence/irrationality of young people by virtue of their age, combine to deny them fundamental rights, demands for which have ‘always been defined as negative, as a challenge to legitimate authority. (Coppock in Clarke 2003: reading 15:9).
Coppock develops this further by arguing that ‘such action is often understood as indicative of ‘dysfunction’ or ‘disorder’ and as such provides a justification for the continued denial of their civil and political rights’ (Coppock in Clarke, 2003: reading 15:9). As we have thus argued, labels of ‘dysfunction’ and accusations of ‘disorder’ are clearly linked to definitions of mental illness.
This argument is also very similar to that used to devalue the demands for choice and the right to be heard of adult mental health service users which means that young people are effectively subject to the ‘dual discrimination of mentalism and adultism’ (Coppock in Clarke, 2003: reading 15:9). Issues of risk and resilience, competence and self esteem paint a pretty poor picture for the young people who use the services of Loughborough Nightstop but it is in these areas that youth and community workers can work towards reducing incidents of mental ill health whilst providing effective services for those already experiencing such.
Actively working towards reducing risk factors whilst simultaneously increasing those associated with resilience we can start to build preventative measures. By providing reconciliation services where appropriate between young people and their families, by enabling young people to take part in social and leisure opportunities that aren’t dependent on their ability to pay and by providing opportunities to explore issues around loss and bereavement we can do much to reduce risk factors.
By working in such a way as to enable young people to build on their self esteem, providing challenging opportunities to encourage problem solving skills and team work experiences to encourage a growth in communication skills, we can increase resilience factors. Working with young people who are living independently we can develop independent living skills so that they can survive the adult world of responsibility and grow into competent adults themselves.
We can do much as workers to provide supportive relationships where none currently exist by encouraging self-help groups and befriending services and ensure young people are heard by a wider audience, community leaders, service providers and policy makers by looking at advocacy and mediation services and actively involving young people in decision making processes. These activities lie at the heart of youth and community work for all people, not just for those with mental health difficulties. None of this however is worth doing if we do not also attack the structural inequalities inherent in present day society.
We can for example, work with an empowerment model that has as its starting point a belief that ’empowerment implies that many competencies are already present or at least possible – empowerment implies that what you see as poor functioning is a result of social structure and lack of resources which make it impossible for the existing competencies to operate’ (McKay in Clarke, 2003: reading 34:17). Our work is therefore not just about enabling people to live with unliveable situations without trying to effect real change on a structural level.
This means being aware of the ideological basis on which much of society is based and the hegemonic standards against which people are being judged so that we can effectively challenge taken for granted ideas and assumptions that are actually social constructs and not unquestionable reality. Our efforts at prevention therefore require ‘the ideological decision to line up with those humanists who believe in social change, in the effectiveness of consultation, in education, in the primary prevention of human physical and emotional misery and in the maximisation of individual competence. ‘ (Albee in Clarke, 2003: reading 26:1050).