No. 11 : May-August 2014

Kristjana Kristiansen

Mental Distress

Academic Foresights

How do you analyze the present status of mental distress?

Attempts to understand and respond to people with serious mental distress remain a major world-wide challenge, albeit often an invisible or unspoken topic. Whatever ‘insanity’ is all about, the way one understands its origins and nature will determine the responses that emerge or not. Such understandings and explanations together with underlying rationales for what are deemed and then sanctioned as appropriate responses often become entrenched as longstanding hegemonies in their societies and cultures. This happens in ways we might call unconscious, since the ways people believe and act happen in ways they themselves are often unaware of. Without an historical gaze, it is difficult to understand the present or predict the future, so allow me to share some thoughts back in time before discussing the present situation or daring to forecast any futures...

Gods and devils, cycles of the moon, and parental sin are only some examples blamed for mental distress, with resultant bizarre and unfortunate responses, yet which are consistent with such understandings of origins and nature of the problem. When gods are perceived as the cause, the individual who hallucinates may be interpreted as a gifted person seeing or hearing important visions and thus deserving respect and positive attention. Or perhaps the individual is infested by the devil and society needs another type of intervention such as exorcism, or ‘mad witches’ require drowning or burning? The word ‘lunatic’ is grounded in explanations that certain people become ‘crazy’ when the moon is in its full phase. Although this began as an idea connected to women and their monthly menstrual cycles, film media images often portray men as having mental disturbances when the moon is full, and the term ‘lunatic asylum’ has been used for mental hospitals long after ‘moon-theories’ were rejected. The notion that parents or grandparents have sinned somehow and have a family member with serious mental distress has also been considered a cause, resulting in serious consequences for an extended family. In many cultures, all of these explanations still linger, and although different in their current societal response patterns typically include suspicion, dislike, and various forms of social rejection and even punishment.

In most so-called developed countries, a medical approach has dominated the mental health field for nearly a century. Psychiatry developed as a specialty from the broader field of ‘rational scientific medicine’, with evolving and expanding explanations for mental distress based on individual pathology, mostly located in the brain. Subsequent ‘treatments’ included lobotomy, insulin-shock, a variety of medicines and other bio-neurological attempts to cure the individual. One exception to brain-based explanations was the diagnosis ‘hysteria’, where women who were seen as ‘crazy’ were diagnosed as having their uterus wandering around their bodies and choking their senses. The element of hope with the medical approach has been that the problem could be diagnosed and cured, occurring in specialized hospital-settings with medically-trained staff as sanctioned experts. Again, the response patterns followed the way mental distress was understood.

Currently, a number of shifts are noticeable. Mental distress is seen as a complex phenomenon with society having an interactive role in creating, maintaining, and also potentially alleviating the condition and situations of mental distress. This shift is often called a move from a medical model to a social model, with the following efforts as responses:

The large segregated, centralized mental hospital-institutions are mostly closed and replaced with smaller, locally-based alternatives. The new community-based services typically include individualized home supports coupled with access to the same services that are available for others, such as schooling, employment, and health needs. A central rationale for deinstitutionalization is that social integration is essential for people in order to change their personal feelings and behaviors: it is important to be with others to learn about how to feel and live and become ‘normal’. Relatedly it is argued that being physically integrated in local communities can change societal attitudes for historically stigmatized groups: local participation will positively influence how one is perceived and treated by others. One might also call this a cultural revolution, since the everyday living conditions in mental hospitals were documented and interpreted as degrading and inhumane, including an even broader ethical and political dimension: that people with mental distress are fellow citizens with the same rights as others, rather than patients and deviants to be excluded and ‘fixed’. Additionally, some power shifts are rapidly occurring, where people with mental distress are seen as experts with lived experience that is unique and perhaps essential in identifying what sort of responses are helpful, and are more empowered to make decisions about their own lives. Most of these shifts are established as official policy at various national and international levels, including the World Health Organization.

In your opinion, how will the situation likely evolve over the next five years?

The above-mentioned numerous ideas and policies seem to be well-intentioned and ones which I personally wholeheartedly support, yet so far appear to be mostly failing, even in a well-resourced country such as Norway. Well-formulated objectives are not the same as actual actions, and my forecast is unfortunately a pessimistic one: people with mental distress in most countries are likely to continue to live on the fringes of society. Exclusion from valued social roles, improved living conditions and true empowerment seem unlikely to improve. Minimal access and supports for higher education and gainful employment are clear examples. Another pattern on the increase is that individualized home-based supports are being reduced, and replaced with ‘ghetto-like’ solutions. Arguments will be debated and diffuse: financial interests because of decreased public funding or ‘for their own good with more effective service’?

Somewhat worrying also is the extra power given to the service recipient and family as ‘expert’ decision-makers, yet often without extra financial or other supports to make informed decisions. Disadvantaged people may be given more power to choose, yet between which real alternatives and with what supports to know the differences to actually change their everyday life situations? Often those who have experienced the least in life will perhaps be grateful with the few crumbs society provides and be satisfied when asked?

Professional clinical mental health interests will struggle to survive. World-wide guidelines, known as the DSM (Diagnostic and Statistical Manual of Mental Disorders) is frequently updated, and has for example eliminated homosexuality as a mental disorder but has added new categories. Each new version of the DSM is reviewed and critiqued, but then eventually supported from internal allies in close fraternity with its medical-educational traditions and the pharmacological industry. One can guess these patterns will continue, with major interests such as ‘Big Pharma’ and mental health professionals as stakeholders and not those truly in need of help: people living with mental distress, their families, and those who want to learn more about how to help them.

What are the structural long-term perspectives?

Such a question demands a double question: what are the likely longer-term structural perspectives, but also what should they be? In a field as elusive as mental distress, predictions are equally elusive as are any recommendations. So I will mostly ask some questions, concentrating on ‘conventions’.

Many place their hope and trust in international conventions, meaning that some higher-level authoritative collective agreement is recorded about what is ‘right’. The world has had the International Human Rights convention since 1948, supposedly for all people. This has been followed by various amendments or clarifications for vulnerable groups including gender, racial origin and age, and eventually more explicit attempts and new conventions targeted in the interests of disability and mental health populations. Most of these conventions are dismissed, ignored or awaiting ratifications in most countries. Well-formulated rhetoric and well-intentioned policies can be expected to continue at most levels, but will this actually help anyone in desperate need? Will there ever be any ‘teeth’ that can bite the offenders of such conventions? In the global context of increasing economic collapse, political conflict and related migration, it is important to seriously investigate and document who is at the greatest risk of being neglected, abandoned or even intentionally destroyed. My hope is that people living with severe mental distress will not be forgotten. And more importantly, that action will be more coherent with well-intentioned policy.

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Kristjana Kristiansen is a Professor at the Norwegian University of Science and Technology in Trondheim, Norway. Her academic background is in psychology and public health, with major research contributions in the fields of mental health and disability reform.

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