The emphasis on control and responsibility is evident in the use of ‘alternatives’ to mainstream therapies on offer in mental health services. Giddens (1992) talks of the notion of ‘lay re-skilling’
where technical knowledge is reacquired or re-appropriated by lay people and routinely applied in the course of their day-to-day activities. ‘Lay re-skilling’ can be framed as a trend towards the
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demedicalization of society with a return to notions of ‘natural’ rather than technical forms of heal- ing, non-compliance with medical treatment and the growth of complementary therapies. Com- plementary and alternative therapies have grown in popularity in recent years both for physical and mental health problems partly as a result of dissatisfaction with conventional medicine. The popularity in mental health of trying alternative therapies in the form of food, diet or herbal medi- cine is likely to have been accentuated by the lack of autonomy and choice inherent in some of the more conventional mental health treatment. Thus, while some alternative therapies do sometimes get incorporated into mainstream services (mindfulness, for example) complementary therapies in mental health can be defined as those approaches found to be therapeutic which are not usually or routinely provided or accessible to individuals from mainstream services (in the UK this would be the NHS). The growing recognition of the use and appreciation of alternatives to conventional treatments is evident in the way in which professional bodies now include information about these different approaches to mental health while acknowledging caveats about the ‘lack of evidence’.
(See, for example, the Royal College of Psychiatrists’ web page on well-being www.rcpsych.ac.uk/
healthadvice/treatmentswellbeing/complementarytherapy/cams1references.aspx.) The use of some drugs such as cannabis represents something of a paradox as being seen as both a cause and alternative form of management. Cannabis use is most prominently seen within the psychiatric literature as being associated with detrimental effects on and risks to mental health (e.g. the onset of psychosis). This has led to calls for the curtailment of its use for recreational purposes (Patton et al. 2002). However, cannabis is a popular alternative therapeutic approach to managing mental health among users. Users have identified cannabis as valuable as a form of self-medication for the relief of symptoms and the side effects of traditional anti-psychotic medication. The benefits of using marijuana are illustrated by this account from a mental health professional working in a community counsellor centre in the USA:
Typically, the people I worked with at the counseling center felt a fondness for marijuana that they did not feel for prescribed psychiatric medications. Zyprexa and Lamictal were dif- ficult facts of life, but pot was a friend. Many said they found cannabis relieved their anxiety and depression, made it possible for them to leave the house and face the world. Judging by my own experience and that of many of my colleagues, as well as a host of online message boards, marijuana is one of the most popular and widely-used unprescribed treatments for mental health problems, ranging from anxiety and depression to attention-deficit and bipolar disorders.
http://crosscut.com/2012/12/27/health-medicine/112098/
marijuana-and-counseling-where-do-we-go-here This intuitive alternative use by services users has links to some scientific evidence that an element of cannabis (Cannabidiol) is effective. Other areas where there is strong commitment by users or potential users of services include the power of spirituality and prayer as a means of overcoming mental health problems. The clandestine use of alternatives such as spirituality arises from a fear that they will not be recognized as legitimate by conventional services. This means that alternative spiritual approaches to coping and help-seeking that are valued by users are not used as part of a holistic approach to managing mental health problems (Edge 2013).
Discussion
Some sociologists have argued that we now live in a therapeutic society in which therapeutic ideas are not confined to clinical and hospital settings but permeate most areas of everyday life.
‘Governmentality’ in contemporary societies is achieved by the self-regulation of our conduct and feelings, and the internalization of psychological knowledge (Rose 1990; De Swaan 1990).
144 a socIology of MenTal HealTH and Illness
This sociological emphasis has increasing salience for understanding cultural trends and the popularity of psychological ideas and therapies, and for the promotion within official policy- making of therapeutic interventions designed to promote individual responsibility and control through population-based training programmes (such as the Expert Patient Programme in Britain or Chronic Disease Management Programme in the USA). These public health policies are designed to encourage individuals to take control and responsibility for their illness and their lives. They emphasize self-assessment, self-monitoring of risk and self-efficacy in managing health and illness in everyday life.
The sociological exploration of psychiatric treatment has tended, itself, to be divided between the poles of the spectrum of service delivery mentioned earlier. On the one hand, it has been con- cerned with critically exposing treatment as mystified coercive social control. On the other hand, it has become preoccupied with those psychological interventions which are ‘anxiously sought and gratefully received’. Sociology is a mirror to the divided territory of psychiatry and, arguably, it contributes to that division.
Psychiatric treatment remains in a precarious state of legitimacy. This uncertainty is then amplified by the doubts about the effectiveness of both physical and psychological therapeutic approaches and the complaints that have accumulated about the iatrogenic effects of these treat- ments. The contradictory picture of psychiatry, mixing as it does both coercion and voluntarism, and an eclectic range of treatments from leucotomy to psychoanalysis, also increases the gap between expectation and reality. If patients entering the psychiatric system expect lengthy explo- rations of their biography and actually get a cursory interview, followed by a prescription for anti- depressants, then the chances of disappointment are great. Likewise, if people look to psychiatry as a source of comfort during times of personal confusion and distress and actually encounter an impersonal controlling regime, with professionals who serve third parties rather than the patients they are supposedly treating, then disaffection is, again, likely.
The uncertainty surrounding the legitimacy of psychiatric treatment is amplified by the struc- tural inequalities in access to the range of its interventions. In other words, as we have explored elsewhere in the book, not all social groups are represented evenly throughout the spectrum of psychiatry. Some receive harsher treatment than others. Black people are less likely to receive psychotherapy and more likely to receive medication and ECT. They are also more likely to be treated coercively than white people. Richer clients can afford to pick and choose between thera- pists in private practice, whereas poorer clients have to take what is given by state-employed professionals in their particular locality. Those diagnosed as being psychotic are less likely to receive psychological treatments than those who are diagnosed as being neurotic. Men are over- represented at the ‘harsh’ end of services.
If entering the psychiatric system ipso facto entailed being treated well, then those groups which are over-represented (like black people) would view themselves as being in receipt of pref- erential treatment. The fact that over-representation is instead a source of concern and anger to these groups reflects the suspicion with which psychiatry is viewed (as being an oppressive part of the extended state apparatus of control). Sociological investigations of how psychiatric patients are treated (in both senses of the word) may need to take on board this complexity and these contradictions. Up until now, two main ‘camps’ of sociology might be seen to have been warring about how to describe and understand psychiatric treatment. The humanistic bias of symbolic interactionism, exemplified in the work of Goffman, contributed to the notion of ‘anti-psychiatry’
and focused on the degradation of the individual and their loss of citizenship. The anti-humanistic bias of the post-structuralists conceives only of discourses which patients and therapists contrib- ute to (or are trapped in). According to this view, individuals are produced, rather than destroyed, by psychiatry.
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The psychological technologies, like the psychotherapies, are indeed now deeply implicated in modern secular society, contributing to the regulation of a moral order and promoting the contem- porary importance of the ‘self’. Arguably, the same is true of an approach which emphasizes the promotion of positive mental health. The problem for the post-structuralist position is that the old humanistic, anti-psychiatric arguments about the coercive power of the State are still highly perti- nent to those groups which continue to be its particular target. It is not surprising that such groups remain hostile to psychiatry, rather than receiving it gratefully when contributing to ‘productive power’. Sociology cannot ignore either the productive technologies of the self or the destructive potential of coercive psychiatry. Both have to be considered together.
In this chapter we have covered a wide range of considerations about psychiatric treatment.
This has included reviewing the literature on specific forms of treatment and the social forces which shape its production and maintenance. Sociologists have contributed to a critical discourse about treatment along with the ‘anti-psychiatrists’ and disaffected service users. At other times, sociologists have suggested that psychiatry is part of a wider set of processes of governmentality.
Overall, sociological scrutiny (exemplified in the work of Goffman) has tended to expose the logi- cal contradictions of treatment. At the same time, the influence of Foucault has focused more on productive power rather than the coercive role of psychiatry in society.
For the foreseeable future, sociologists are likely to retain an interest in both of these aspects of professional mental health work. However, the notion of social exclusion and the need to reverse the effects of the role of being a psychiatric patient through social and economic opportunities suggest a broadening focus to the traditional notion of treatment. This may mean that mental health workers and psychiatrists in particular will be placed in the increasingly ironic position of ameliorating the distress caused by the labelling, treatment and management created by their own professional actions.
Questions
1 To what extent are treatments used to manage private troubles, and public social and structural issues?
2 does psychiatry produce or crush subjectivity?
3 How can non-compliance with psychiatric treatment be understood?
4 Why does the ‘inverse care law’ not apply in psychiatric services?
5 What problems are associated with the concept of insight?
6 To what extent does goffman’s work on large mental hospital life still apply today?
7 discuss the rationale for evidence-based mental health care and barriers to its success.
For discussion
consider whether you would be prepared to volunteer for psychiatric treatment if you became psychologically distressed. What would be the pros and cons to consider in this decision?