Emotional health: challenging biomedicine or increasing health surveillance?

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Emotional health: challengingbiomedicine or increasing healthsurveillance?Gillian Bendelow aa Department of Sociology, University of Sussex, Brighton, UK

Available online: 20 Nov 2010

To cite this article: Gillian Bendelow (2010): Emotional health: challenging biomedicine orincreasing health surveillance?, Critical Public Health, 20:4, 465-474

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Critical Public HealthVol. 20, No. 4, December 2010, 465–474

Emotional health: challenging biomedicine or increasing health

surveillance?

Gillian Bendelow*

Department of Sociology, University of Sussex, Brighton, UK

(Received 22 October 2009; final version received 18 September 2010)

In general practice in the UK, the term emotional health is increasinglybeing used to address an ever-increasing range of consultations whichinvolve distressing symptoms which combine mental, physical and socialaspects of health and wellbeing. Practitioners often despair of being able totreat these complex conditions with traditional biomedicine, as they areoften manifested through medically unexplained symptoms, hence the turnto more holistic or integrated models of health and illness, which are nowpermeating many areas of medical education and health care practice.Instead of the ‘quickfix’ response of psychopharmacological treatment,psychotherapeutic therapies, such as cognitive behavioural therapy orsocial interventions, such as exercise programmes may be considered foralleviating anxiety and depression. This article considers whether the focuson emotional health offers a potential and enlightened way forward inaddressing the mind/body/society interface in contemporary health careand health promotion.

Keywords: emotional health; mental healthcare; biomedical model; medi-cally unexplained symptoms; integrated healthcare; wellbeing

Introduction

In the so-called ‘developed’ world, biomedical advances have undoubtedly bestowedbenefits of increased life expectancy and protection from infectious disease, whichenhance the quality, as well as, the length of life in wealthier societies. However, bythe twenty-first century, diagnostic categories have expanded greatly, not least withthe patterning of health and illness associated with longevity and emotional/mentalhealth, demanding multifactorial aetiologies which require traditional categories,formulations and management strategies to be re-evaluated. In particular, theproliferation in late modernity of conditions with ‘medically unexplained symptoms’emphasise more than ever, the limitations of the divisions between mental andphysical health. These may range from complex idiopathic pain and chronic fatiguesyndromes through a range of eating, sleeping, behavioural and anxiety disorders,but are characteristic in that they combine distressing bodily symptoms with oftensevere emotional disruption and functional impairment (Nettleton et al. 2004).

*Email: [email protected]

ISSN 0958–1596 print/ISSN 1469–3682 online

� 2010 Taylor & Francis

DOI: 10.1080/09581596.2010.518382

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This article explores the implications of contemplating emotional distress ormental disorder in terms of emotional health rather than mental illness. The role ofemotion and stress in contemporary patterns of health and illness demandsconsiderable rethinking across the traditional divisions between mental and physicalconditions, in order to transcend not just the split between mind and body, but themind/body/society divide (Freund 1990). In turn, this entails a re-examination ofcritique of the medicalisation of emotional distress/disorder, with a particularemphasis on the limitations of the biomedical approach to aetiological factors, withsubsequent consequences for diagnosis and treatment. Finally, the benefits of a moreholistic and seemingly enlightened rubric of emotional health, which encapsulates thesocial as well as the biological and psychological need to be considered against thebackdrop of the potential for increased surveillance and social manipulation thatthe spectre of healthism raises.

The medicalisation of emotional distress

The manifestation of emotional distress is endemic across all cultures, althoughinterpretation and responses may vary widely (Rogers and Pilgrim 2010). Acrossmost of so-called ‘western’ society, madness and emotional instability has alwaysaroused public response and intervention. Since the nineteenth century, theseinterventions in the form of scientific medicine in general, and psychiatry inparticular, have meant that medicalisation has been the most dominant means ofresponse (Foucault 1976, Porter 2002) and the development of biological andneuropsychiatry has largely dominated therapeutic responses to emotional distressfrom severe psychotic mental illnesses at one end of the spectrum to the ever-widening range of neurotic, anxiety and minor depressive disorders at the other.Although the medicalised responses of ‘western’ psychiatry to emotional distresshave long acknowledged and included pluralistic approaches, such as talking curesand psychosocial interventions, the so-called biological treatments, particularly in theform of pharmaceuticals, have dominated the field of psychiatry and emotionalhealth. This trend continues into the twenty-first century with the focus on thegenomic agenda giving rise to a renewed emphasis on seeking biological and geneticcauses through brain imaging and other highly technologised forms of research.However, the limitations of this biomedical response are subject to enormouscontroversy in the form of pharmaskepticism, namely the dominant tendency to relyon pharmaceutical or technical interventions for simplistic solutions to highlycomplex illness syndromes.

Throughout history, the mentally ‘disordered’ have always been socially andlegally marginalised as citizens and in the first half of the twentieth century in theUK, there was an administrative and geographical separation of those termedmentally ill and mentally defective. In contemporary UK society, under the moregeneric but still contested term of disability, care and treatment has historically beenseparated out from those designated as mentally ill who were cared for in mentalhospitals, the reformed Victorian asylum (Pilgrim 2005). Reaching their peakbetween the 1950s and 1970s, the criteria for hospital beds for the mentally illincluded the ‘morally deficient’, but the aim was cure through medical treatment,often administered involuntarily with the aid of the 1953 and 1983 Mental HealthActs. Distinctions have always been made between psychotic and neurotic

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manifestations of mental disorder, with the former signifying a rupture with reality,

however reality may be defined, which of course is much debated.Contemporary mental health care in the UK categorises psychoses as serious

mental illness (SMI), irrevocably associated with ‘dangerousness’ as defined by the

Mental Health Act (1953, 1983) as the propensity to harm self or others. The

potential for psychiatry to be an agent of social control has a long history associated

with the development of the asylum and the expansion of psychiatric power-

knowledge into new terrains (cf. Foucault 1976) and the medicalisation of social

deviance (Conrad 2007). Despite the closure of many of the old asylums and mental

hospitals throughout the 1980s and 1990s, SMI services remain segregated from

general medicine and is largely treated through psychiatric units and mental

health teams.In contrast, neurotic disorders are treated predominantly through primary care,

mainly GP prescriptions for pharmaceuticals in the form of selective serotonin

reuptake inhibitors (SSRIs) and other controversial mood altering drugs, such as

Ritalin. For instance, depression can be conceptualised across the entire lay/medical

spectrum, from the ‘normal’ highs and lows of the human condition to being

included within the dominant Diagnostic and Statistical Manual (DSM) and

International Classification of Diseases (ICD-10, WHO) classificatory systems, as a

form of SMI involving severe psychosis and self-harm. The current version of DSM

IV (American Psychiatric Association (APA) 1994) identifies seven categories and

sub-categories relating to depression (Horwitz and Wakefield 2007). However, in

countries, such as the UK and Australia where GP consultations are usually the

initial mechanism for help-seeking, diagnoses of depression are increasingly made in

primary care settings, rather than by psychiatrists in mental health services, and a

recent study in the UK identifies 19 different labels for depression currently in

professional use (McPherson and Armstrong 2009). Diagnostic guidelines for

depression are generally based on a medical model of care, and, until recently, have

recommended antidepressant medications as the treatment of choice (McPherson

and Armstrong 2009). Since SSRIs, such as Seroxat and Prozac were introduced and

marketed in the 1990s as ‘quickfix’ wonder drugs without the toxic side effects of the

previous generation of antidepressants, concern has grown over the rates of

prescribing (in England, from 9.9 million in 1992, to 27.7 million by 2003) and the

increased incidence of sinister side effects, such as self-harm, suicide and even alleged

homicide (Mental Health Foundation (MHF) 2005, 2010). Within the UK, the most

recent National Institute for Clinical Excellence (NICE 2009) guidelines are very

clear that antidepressant medication should not be prescribed for sub-threshold or

mild depression, but recommend instead these forms of psychosocial prescribing:

– individual guided self-help based on the principles of cognitive behavioural

therapy (CBT),– computerised CBT,– structured group physical activity programme.

A recent survey of 200 GPs found that 57% thought that antidepressants were

overprescribed and that 78% prescribed antidepressants as first treatment choice in

the last 3 years despite their belief that an alternative therapy would have been more

effective (MHF 2010). Less than half the sample had access to CBT programmes or

exercise therapy. So although there may be an ideological shift towards ‘social

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prescribing’ and non-medical therapies, it is far from certain that these are readilyaccessible, at least in the UK.

The more controversial behavioural conditions, such as substance misuse andpersonality disorders (including parasuicide and self-harm) are increasingly treatedoutside the National Health Service (NHS), if they are indeed treated at all. Busfield(2002) has provided a helpful distinction between disorders of thought, emotion andbehaviour, which can be in turn be translated into patterns of diagnosis and healthcare (Table 1).

In contemporary Britain, the resource-starved mental health services areincreasingly directed towards chronic psychotic illness (SMI), in line with a moregeneral trend towards risk assessment and aversion (Wolff 2002, Corbett andWestwood 2005). To an even greater degree, the substance misuse services remainlow priority, much as they always have been, and addictive or self-harmingbehaviour may be portrayed almost a lifestyle ‘choice’. Complex referral schemesand long waiting lists are significant barriers to alcohol and drug detoxification andrehabilitation programmes, which are increasingly, linked to probation and crimereduction services, further stigmatising those seeking help. Again, funding is scarcefor the majority who have no resources for private clinics, so there are enormoussocio-economic and geographical differences, epitomised by the highly publicisedcelebrity rehab culture in stark contrast to the grim reality of the addict living on thestreets.

Ironically, a distinction emerges between the disorders of thought, namelypsychoses (i.e. ‘real’ or ‘serious’ mental illness which abdicates individualresponsibility and requires treatment which may be justified as coercive) and the‘less serious’ disorders of emotion and behaviour which can be subsumed underthe rubric of emotional health. Paradoxically, although there is more apparentopenness, as well as unprecedented access through social media to knowledgeand information about conditions, such as reactive (cf. psychotic) depressionanxiety disorders and even of the range of addictive behaviours (Nettleton andBurrows 2003), emotional health has the propensity to place the onus ofresponsibility very squarely on the individual. Although the concept of emotionalhealth can address the problems of the mind/body divide and may facilitatethe destigmatisation of ‘mental disorders’ (at least those which are not associatedwith psychosis or ‘dangerousness’) to some extent, it still tends to be the casethat illnesses without clear and demonstrable scientific physiopathology remain atthe bottom of the hierarchy. Across the whole range of medical care and practice,psychiatry and psychiatric treatments have always been, and still are, subject tohuge controversy, less prestige and receive less funding for research.

Many of the conditions included under the category of emotion and behaviourwere previously seen as either ‘deviant’ (such as personality disorders andaddictions) or as the extreme end of ‘normal’ behaviour rather than as illnesses,such as attention deficit hyperactivity disorder (ADHD), eating disorders and theanxiety disorders including post-traumatic stress disorder (PTSD), seasonalaffective disorder (SAD), generalised anxiety disorder (GAD), so are subsequentlycontested as to whether they are ‘real’ illnesses, and are subject to greatcontroversy within the medical press, the media and the general public (Smith2002, Jutel 2009). In turn, treatments and therapies for these conditions, unlessprivately funded by the individual, compete alongside other constrained resources,including the mental health services.

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Table

1.Diagnosisandtreatm

entof‘emotionaldisorder’in

contemporary

Britain.

Disorder

category

Diagnosis

Treatm

entprovider

Nature

oftreatm

ent

Thought

SMIe.g.schizophrenia,bipolar

disorder,psychoticdepression

Referralmainly

throughGPor

primary

care

toMHS(hospital

andcommunitycare)orprivate

clinics

Psychotropic

drugsanddepot

injections

Physicaltreatm

ents

e.g.electrocon-

vulsivetherapy(ECT),brain

surgery

Behaviouralandpsychodynamic

therapies

Emotion

Anxiety

anddepressivedisorders

Behaviourale.g.ADHD

Eating(e.g.anorexia)andsleep

disorders

80–90%

oftreatm

entin

primary

care

(GPs)

Somespecialist

referralonNHSor

private

consultations

Pharm

aceuticals:mainly

SSRIs,

Ritalinetc.

Behaviouralandpsychodynamic

therapies

‘Socialprescribing’

Behaviour

Substance

misuse

andaddictionse.g.

drugs,alcohol,sexualoffenders,

personality

disorders

Outsidemainstream

NHShealth

care,specialist

services

someself-

referralandprivate

‘rehab’clinics

Detoxificationregim

esBehaviouralandpsychodynamic

therapiesespeciallyCBT

Source:

Bendelow

(2009),p.67(after

Busfield

2002).

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Healthism and disease mongering

Over the past decade or so, a movement amongst health professionals, socialscientists and service users has emerged, combining of critiques of healthism with

those of disease mongering and pharmaskepticism.It takes as its starting point Beck’s notion of an overanxious insecure ‘risk’

society (1992) as characterised by the fragmentation of social networks and

communities and the atomisation of individual (i.e. the isolation of individualswithin homogenous social groups). Within this context, health now becomes a goal

to be endlessly pursued if rarely achieved, and it has become inextricably linked withindividual attitudes, commitment and personal responsibility (Lupton 1995, Petersen

2007). Contemporary health care is dominated by evidence-based practice, making

decisions on the anticipation, rational calculation and attempted management offuture hazards (Lupton 1995, Corbett and Westwood 2005). Risk assessment, risk

appraisal and the construction of risk profiles for potential ‘offenders’ whetherlegally or socially defined are powerful tools in the discursive armoury of politicians

and policy makers, serving the function of population governance (Wolff 2002).Thus‘perfect health’ becomes a dogma in the form of healthism; a highly individualised

and consumer-orientated pursuit, involving not only self-transformation and self-improvement of our bodies and our appearance (Petersen 2007) but also our

emotions, behaviour and our values.The term disease mongering was coined to describe the creation of ‘new’ illnesses

which may often fit the interests of the pharmaceutical industry (Moynihan 2002).

With the imminent expansion and further proliferation of illness categories in thenext volumes of the major diagnostic manuals (DSM V and ICD 11), concern has

been expressed with regard to both the vagueness of diagnostic criteria and seemingly

endless expansion of the boundaries of what can be termed emotional disorder.As described earlier, the example of clinical depression which spans the diagnostic

classification through mild moderate and severe, lists within its criteria, vague value-laden symptoms, such as dysthymia (‘inappropriate’ feelings). Despite the develop-

ment of more innovative psychosocial interventions and radical developments in‘social prescribing’, such as exercise therapy, the overwhelming clinical response to

emotional dysfunctionality is medicinal, further resulting in ‘chemically assistedselves’ or cosmetic psychopharmacology (Lyon 1996), underpinned by both the

soaring prescription rates and bottomless demand for the ‘new’ antidepressants in

the form of SSRIs, such as Prozac and Seroxat, and other mood altering drugs, suchas Ritalin. In addition, what was previously seen in lay terms as social support can be

seen as the professionalisation or commodification of emotionality through thepresent day proliferation of reality TV, internet and social media (Petersen 2007).

The increased life expectancy and material comforts in the ‘developed’ world do

not appear to have resulted in either happier or healthier populations, as incidencesof chronic illness and emotional distress escalate alongside the expansion of illness

categories and prescribed medicines. Gaining much currency are popular argumentsthat the socio-economic improvements of life in the so-called ‘western world’ have

meant that whereas those societies rarely or never experience severe hunger orpoverty, droughts and extreme climate conditions or infectious diseases that kill,

nevertheless they are in the midst of epidemics of depression, anxiety, substancemisuse and eating disorders. These have been interpreted as a socially constructed

luxury of a spoiled narcissistic society obsessed by material envy, body image,

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celebrity and reality TV. The concept of affluenza has been enthusiastically adoptedby broadsheet media to describe this paradox of ‘luxury fever’ in quasi-medicinal

terms – a middle class ‘virus’ brought on by the social and material envy of a societyobsessed by:

flash holidays, luxury furniture, big salaries and expensive cars . . . individualismreplaced by consumerism as the aspirational middle classes shackle themselves tounfulfilling jobs, working excessively long hours and cutting themselves off from properrelationships (James 2007, p. 23)

Many critics of individualism and consumerism, such as Furedi (2004) haveindicated a growing tendency for social problems to be interpreted as ‘emotional’,

and for highly individualised idioms of therapeutic discourse to be used to makesense of social isolation, through discourses of being ‘stressed out’ ‘burnt out’ orhaving ‘mid-life crisis’. In this characterisation of society, the use of personal

inadequacies, guilt feelings, conflicts and neuroses to replace abstract, almostinvisible social influences, such as globalisation, market forces, cultural and politicalinstitutions, in other words the tendency for ‘social and cultural influence to bediscounted in favour of narrow psychological contemplation’ (Furedi 2004, p. 25).

The avoidance of negative emotion, seen as ‘unhealthy’ or ‘pathological’ to feeldissatisfied, disillusioned or miserable is all too readily absorbed into post-Thatcher/Reaganite culture of 1980s individualism and, he argues is not an enlightened shift.

He contends that the emphasis on achievement of personal happiness and fulfilmentthrough self-discovery, self-assessment and self-actualisation has resulted in self-esteem becoming the important explanatory variable. In turn, low self-esteem

becomes an over-arching explanation for socially perceived ‘problem’ groups such asteenagers, unemployed, elderly, mentally ill, lone parents or the disabled so that‘society is much more comfortable dealing with poverty as a mental health problemrather than a social issue’ (Furedi 2004, p. 27).

Thus, psychosocial overdeterminism in understanding health and illness is, for

some critics, potentially as dangerous and as reductionist as biological supremacy.Examples of this can be seen in health promotion literature and risk assessmentswhich purport to transcend individualism by using research evidence to target wider

social groups who are perceived to be more at risk because of their postcode or eventheir ethnicity. For example, New Zealand Guidelines Group (2009) on preventingcoronary heart disease identify Pacific Islanders as being at risk on average 10 yearsbefore their European counterparts (NZgg.org.net 2010), in the same way that

biological age is used to assume vulnerability.

Emotional health: integrated models of health and illness

Integrated models of health and illness are increasingly permeating contemporaryhealth care, and are gaining popularity and credibility within the mainstream medicalliterature and research, as the limits of biomedicine become increasingly evident in

contemporary times (Wade and Halligan 2004). Integrated models also challengetraditional sociological assumptions that doctors are only concerned with biological(disease) and that the social (illness) is of concern outside medicine as GPs and health

professionals are presented every day with issues relating to social causes of ill-healthand the social contexts of ill-health and lifestyle (Hansen and Easthope 2006).

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However, conceptual, political and practical balance must be borne in mind if thenotion of emotional health is to have viable currency.

As discussed earlier, contemporary health care is inevitably dominated by thepractice of evidence-based medicine (EBM), but integrated models are able to engagewith the principles of values-based medicine (VBM) which are not necessarily inconflict or attempting to be a substitute for EBM, but an attempt at a pragmaticrapprochement. VBM highlights the role of communication skills, the relationshipbetween ethics and law and the role of medical humanities in medical practice.VBM begins with the premise that values and subjectivity affect every stage of theclinical encounter (Fulford et al. 2002) and integrated models which challengebiomedicine are particularly developed in the mental health arena. For example, thepost-psychiatry movement (Bracken and Thomas 2006) provides a pragmatic andviable new direction for intervention into emotional distress. Whilst accepting manyof the critiques and conceptual frameworks of anti-psychiatry, practitioners of post-psychiatry accept that emotional or mental distress is ‘real’ in the sense thatintervention, usually clinical, is needed to alleviate the often severe problemsexperienced by individuals.

They also accept that psychiatry is the dominant mode of dealing with distress,however limited diagnoses and treatments may be. By the practitioner accepting andworking with the diversity of their own and others values, opportunities arise fordiscussion, consultation and negotiation. In other words, the medical model is usedas the basis of providing intervention, but diagnosis and treatment are negotiatedwith the client/user/sufferer (terminology may vary but ‘patient’ is less likely tobe used). Built on the principle of ethical reasoning, this approach emphasises thesignificance of social, political and cultural contexts for the understanding of mentalillness and draws attention to the importance of values, rather than causes, inresearch and practice, giving rise to a so-called ‘new philosophy of psychiatry’prioritising interpretation and meaningful experiences (Fulford et al. 2002). Usermovements have long argued the need for open, genuine and democratic debateacross the lay/professional divide and against individualistic frameworks centred onmedical diagnosis and treatment. In this model, a range of interventions, includingradical and innovative developments in ‘green’ and ‘eco’ therapies, as well as popular‘talking cures’ provide viable alternatives (MHF 2010). In addition, the recentgovernment policy emphases on social exclusion and partnership in health are viewedas an opportunity for a ‘new deal’ between professionals and service users. Post-psychiatry proposes a new relationship between society and the emotionallydistressed, challenging health care professionals and providers to rethink their roleand responsibilities, by building on critiques of anti-psychiatry and the failures ofcommunity care (Bracken and Thomas 2006).

In conclusion, it can be argued that recent shifts, which may be socio-political(as in the perceived rise of ‘risk’ society), epidemiological (as in the return ofinfectious disease epidemics) and ecological (the visible material impacts of globalclimate change) have resulted in both conceptual and practical reorganisation ofmedical ideologies and practices. Integrated models which recognise the conceptof balance, based on the traditional Hippocratic view of the body as a microcosm ofnature is crucial to the process of intellectual and conceptual thinking, as it is inunderstanding and constructing models of health care which encapsulate the social ina meaningful way, as opposed to the often tokenist or utopian rhetoric which oftenpervades health policy. The dissolution of the unhelpful divides between mental and

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physical health form an essential part of developing a wider mind/body/societyperspective, as well as more enlightened mental/emotional health care.

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