Sociology, Culture and Psychiatry Dr Alex Hunt Clinical Psychologist.

Sociology, Culture and Psychiatry

Dr Alex HuntClinical Psychologist

Conceptions of Mental Health

• Psychiatric• Biomedical model – mental illness approach• developed from physical medicine

• Psychoanalytic• Conflicts • Deficits

• Psychological• Statistical notion• Ideal notion • Presence or absence of specific behaviours• Distorted cognitions

Conceptions of Mental Health

• 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

Normal Abnormal

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

• 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)

Chronic condition

corpse

Becoming ill

SICK!

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

Active

Chronic

Patient as sacred

Patient as shameful

Passive

Acute

“Angry”

“Scapegoated”

“Baby”

“Corpse”

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

• 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?

Variation in presentation of symptoms / epidemiology across cultures

Biological Social Cultural

Hypothesised influence on presentation

Amok

Latah

“psychosis”

Depression

Personalistic

Culture and Category

Anorexia & Bulimia

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