What is a mental health problem?

The contemporary field of mental health is characterized by a crisis, one that mirrors struggles between both actors and interstices between many different ideas about the nature of mental health problems, disorders and so on. Exactly what do these mental health challenges entail, and how we can understand them?

Show Notes

These questions are by no means agreed upon, and various stakeholders seem far apart when arguing their case. This discussion, intended as a learning activity in the SoWGloW project, we touch upon some of the theoretical points of departure and what consequences they might entail. 

References in the episode:
Rose, N. (2019). Our psychiatric future: the politics of mental health. Polity.

In the podcast:

• Knut Tore Sælør - Associate professor USN
• Jeppe Oute Hansen - Associate Professor, USN

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A podcast about international social work. Made by SocNet98, an European network of 18 universities that graduates students in social work. In this podcast you can listen to a broad specter of topics that is all connected to social work in an international perspective.

Welcome to This Social Pod, a podcast brought to you by Cygnet 98,

a network of universities sharing the common interest for social work in an international perspective.

Hi, and welcome to this episode of The Social Pod.

Today we're going to have a dialog between myself to research,

Associate Professor and mental health care from the University of South East in Norway and associate professor in mental health care,

also at the University of South south eastern Norway. And as a point of departure for this dialog.

We will start off by discussing what some people call a crisis in psychiatry.

What is a mental health problem? What is mental health?

What do people who experience mental health issues need?

A crisis in psychiatry. What is that all about?

Yep. I guess in the first instance, it's it's a very difficult question, so to answer.

But. But I guess that it's a it's.

It's a crisis that mirrors a number of power struggles between different actors in mental health.

But equally as important, it is also a a matter or a crisis that mirrors different consistencies between different notions of

mental health or mental health problems or the disorder or distress or whatever you might call it.

So it's a it's a broader discussion about the basic categories in mental health, I guess.

And if we go to a quite well-known sociologist and author Nicholas Rose, he argues that there is no one psychiatry.

Psychiatry is heterogeneous with many different and sometimes incompatible conceptions of mental disorder, many different treatment practices.

What does that mean? Because I've I have a background in psychiatry, but it's not that easy, is it?

There's always struggles and different perceptions.

Indeed there is. And I suppose if you just look at this crisis from a incident, from a discipline disciplinary angle,

it very quickly becomes clear that the psychologists as sort of generally speaking,

seem to abide to two different notions, or at least very often applied to different notions of the so called mental disorder than,

for example, psychiatrists or social workers or nurses for that matter, do.

So we have this sort of interdisciplinary landscape.

In which different actors or different disciplinary groupings tend to abide to different notions of.

A core category. So we see these kinds of sort of theoretical struggles about this concept that in some sense

guides what should be done and how we deal with mental disorders more broadly speaking.

Yeah, and I'm a nurse myself, and one of the things I think I've learned is I often compare theoretical, theoretical perspectives,

perceptions of mental health with kind of glasses where when I wear sunglasses, I see a different things.

So maybe a sociologist sees other things than myself.

But he argues, Nicolas Rose, that even psychiatrists who.

Often are considered biological. Their understanding and diagnosing and way of treating disorders are quite different.

Why is that, you think? Well, I guess that the point that he's trying to make, at least in so far, I'm correct in my in my way of reading him.

I guess the point he's trying to make is that that psychiatrists, psychologists, nurses, etc.,

those who practice in the front line of mental health very rarely rely on so-called pure perspectives and positions.

They tend to to have a more blurred conception of what disorders or mental health problems might be,

and not because they are necessarily theoretical and concise,

but because they have to abide to different notions to in order to provide coherent, timely, accurate help to the individual.

Well, so I guess that debate is a more idealized debate, really, that the crisis is an idealized crisis because most practitioners,

according to Rose, might in fact use a very broad set of conceptual tools to diagnose and to treat people in individual cases.

And one thing that fascinates me, at least that's the fact that no matter what kind of stance you take.

What? You meet our fellow human beings.

And this also is connected, in my mind, at least, to what you consider a human being to be.

And some people would say that mental health problems is a brain disease, for example.

What's your reaction to that? Well in so far that.

Then the notions of mental health problems or disorders or distress.

It's attached to sort of the broader history of ideas and.

Different ways of viewing the very idea of man.

I guess you're right. This this crisis does tend to echo or at least mirror a broader history of ideas in at least in Western industrialized contexts.

So. That's really sort of important and deeply rooted ideas at stake in this debate and things that might even make it impossible,

or at least very difficult to reach consensus in all of these battles.

Why do we need to battle?

Well, I'm not sure I can come up with an accurate answer to that question, but but I have a is a very brief narrative that, at least to me,

suggests that suggests why a good colleague of mine who is now a retired professor and he argued at some point that as a clinical psychologist,

he he would have to carry around a very large theoretical toolbox.

Because he would not he couldn't in advance say what determined the nature of the individual's problems.

So in order to actually provide help that was meaningful and accurate in each individual case in his clinical work,

he would have to to be good enough to actually pull out different concepts and ideas to

accurately grasp what was at stake for the individual rather than sort of paradigmatic,

paradigmatic lay applied to, say, for example, biological psychiatry, that perspective or neuro psycho neurocognitive psychology.

Or a third one. So I guess that he argued in this in his narrative that that he would have to

be a collage type of clinician that embodied so many different perspectives.

And he didn't really he wasn't religious about it is a way of of of saying

that we need to be theoretically well equipped to to to actually provide help.

And would you agree? That some.

To some extent, our education, our way of being socialized into different ways of perceiving mental health issues will reflect in our practices.

Certainly. Being educated and socialized into a a school for that matter.

Inside a certain discipline is also involves being unlearning other stuff.

So you're sort of focusing in each across different disciplines.

You're focusing on different aspects of of mental health problems, say for instance, in psychology, psychiatry, nursing, social work, etc., etc.

So I guess. The stances you take highly depend on your educational background.

But but of course. But clearly it's more complicated than that, because we also see a tendency to say that this sort of age,

gender class also also work as a determining factors and in the sense that practitioners tend to have by two different perspectives.

So one thing that might be important is being critical.

Try to reflect on what you're part of yourself and the practice you're a part of and the kind

of education you've been or the things you've been taught and be open to other perspectives.

For instance, for social work would perceive a situation different than a nurse.

Well. Well, absolutely. But but I guess some practitioners might.

Might find it somewhat easier to sustain what some people would articulate as open minded towards other perspectives and others.

And if you if you use a concept from some discourse theory,

you could argue that some some perspectives have a more closed discourse around mental health problems.

It is, for example, well known that the biomedical discourse is somewhat more closed and less open to other perspectives than,

for instance, existentialism and recovery oriented care or or different notions of what problems might be.

And if it go back to Nicolas Rose. And I guess this isn't his thoughts alone.

But one important thing and one great battle, at least in my mind, has been diagnosis and the use of diagnosis and how important they seemingly are.

And you referred to the Western world. I'm not sure I have a clear conception of where that is or exactly what it is, but.

I think. And I believe that diagnosis and the use of them, the importance of them, is quite.

Great in the Western world. Why is that, do you think?

Well, if in literature at least and again, we've seen a number of scholars considering this issue for.

Quite a few years now, and at least in the last decade.

And one of these scholars have been Nicholas Rose.

And what we've in the Nordic region, we've also seen scholars like this psychology professor of psychology, Stephen Blakeman,

and the associate professor and sociologist Alice Peterson,

who have argued that that that yes, diagnosis might have a a of course, a clinical relevance.

Absolutely. And they might reflect pathologies in the individuals that might be.

But they at the same time also reflect broader societal tendencies.

In fact, Petersen have argued that. That it's sort of the the negative side of of of of sort of the virtues in contemporary society.

So so very easily it should be very easy to see that that that diagnoses are deeply rooted.

And our our our view of diagnoses and cultures is deeply rooted in history and in our material surroundings,

in the ideologies of contemporary society.

So so rather than being independence, rather than being just biological truths in their own rights, so to speak.

And depending on what direction or where you stand, I guess the solution is there is a solution.

But the way. Out or how to get support.

How to recover will be different.

Depending on where you stand. Indeed.

It's this sort of sort of participatory approaches, like, for instance, recovery.

You could name quite a few. Participation, empowerment, patient and public involvement, etc., etc.

These are these names. But. But recovery is the nature of recovery.

And it's a quite hotly debated issue in mental health and has been for.

Also at least a decade. And if we go back to some of the early debates and a the American professor, David Davidson, who is a professor at Yale,

has argued that the very notion of recovery can be identified at the very onset of clinical psychiatry as we know it,

but that the concept has evolved and developed, reemerged in a number of different guises over the years,

and so many different people have tried to categorize and I'm tempted to say, diagnose the nature of recovery.

Since then. For instance, we've seen the British professor Mark Slade, having sort of.

Categorized different notions of recovery.

And he talks about clinical recovery and personal recovery and.

And these ideas are said. You have roots, theoretical roots and ideological roots in quite different views of.

Good psychiatry. Mental health care. So could almost say their recovery field has its own battles.

Indeed. I think the the struggle over recovery at the conceptual level and at the political level,

I think that in many ways it sort of mirrors some of the broader power struggles and conceptual discussions and debates in the field.

But it but it certainly has. It's sort of.

You can consider it, this debate on recovery and this the very question of what is recovery?

It's all you can consider that.

And then so in its own right, I suppose it's what I have read about recovery.

It's in its. Genesis.

I guess human rights. Civil rights were important.

Um. Including contexts.

Not considering mental health.

A brain disease was important, but part of the criticism has been that recovery now is co-opted, that professionals decide what recovery might be.

It has to be according to the guidelines that traditional mental health services provide.

So there seems to be, but I guess that's society in general.

Everything evolves. There are battles.

You could argue that this is recovery.

This is mental health. And different people have different stakes in that discussion or discourse or battle or whatever.

Yeah, well, I guess I guess that at least one could argue that the the debates about the

nature of recovery might not just mirror the two debates about the disorder.

It might also debate evolve around the the question, how do we develop welfare services that actually act accurately and adequately and timely,

provide services to people in ways that people find meaningful and helpful, etc.

And so if you. If you go into depth with that discussion, I suppose that the the reproductive forces of of psychiatry.

Where where patients are considered chronic and in lifelong need of services from the system.

And the system continues to to some legitimately make decisions about what the patient needs.

Is is sort of under attack from the user and from the of movement on the critical survivor movement, from the recovery movement.

And in that sense, you can see that it's it's it's a very broad discussion about why we even have psychiatry in contemporary society.

And this is a very long and complex history. But but I guess it's it's it's closely attached to the notion of mental health problems.

Although it might not solely reflect that question.

And just to get back to Slate's outline of recovery,

which is which is at the center of this sort of overarching debate about the development of welfare services,

you could argue that the clinical recovery is rooted in a sort of medical notion of the mental disorder,

whereas personal recovery is is more rooted in,

in part in existentialism from Nordic existentialism, for example, but also attached,

or it also resonates well with bits of Frankl's meaning making theory and later developments

from from the empowerment movement that emphasizes notions such as citizenship rights,

etc. So it's really recovery plus the recovery has really become this concept that it constantly,

constantly develops and adds new layers to the discussion.

And at least to me, this makes it very difficult to pinpoint what it is and what it isn't and how it differs from clinical recovery,

which might seems a little more straightforward.

So many practitioners, and sometimes I have the impression that one thing is more things at the same times.

So in an educational situation or a debate, making clear where you stand and what you perceive mental health to be would might be a good start that.

Yes. I guess that if we if we were to to reflect more systematically in education and and frontline

practices on the very notion of of of mental health problems or distress or whatever you might call it.

I, I guess that. It would be a good idea to actually consider the you say,

the open positions that you could take and you could you can identify various positions and media, you can identify various positions in literature,

you can identify various positions and in informal theory, in mental health, for example,

the medical position or a psychodynamic one and neurocognitive one or a more sort of humanistic psychiatry and say a more relational approach.

So there are so many different ways you can conceptualize the very idea of of of mental health problems.

And, and I guess that would be a good starting point for a debate that attempts to actually debate rather than close the debate.

Yeah, because some people would argue that mental health isn't a brain disease, it's not even individual, it's relational.

And that would be pointing at a quite different direction than a biological view, I guess.

Well, yeah, but but I and I guess that point, the point you're making is, is, is correct from a certain point of view.

So I guess that.

One can make the observation that if if if there is a characteristic or generic trait and the debate around the nature of mental health problems,

one would be that we tend to judge.

One perspective and perspective from the perspective of another.

And at least theoretically, theoretically, that's not how things work.

You have to take your point of departure in the assumptions and perspective

of the particular perspective to actually debate whether or not it's valid.

So say a psychiatrist by fire, a psychiatric psychiatrist wouldn't be able to make true judgments about a humanistic

position from the from the point of departure of medical psychiatry and vice versa.

So. So it really requires that we are quite advanced in our theoretical understanding to actually go into,

say, more sort of democratic debates about the basic categories in mental health care.

Okay. Thank you. Yeah. Thank you.