SOCIAL PSYCHIATRY

 

There are numerous definitions of social psychiatry, and clearly social factors are relevant in all aspects of psychiatry.  However, social psychiatry is particularly concerned with:

 

1.         social factors associated with the onset1 course and outcome of psychiatric disorders

 

2.         social effects of mental illness

 

3.         psycho-social disorders

 

4.         social approaches to prevention, treatment and rehabilitation of the psychiatrically ill.

 

A number of these issues will be covered in this lecture with a concentration on contemporary issues which may be relevant to the exam.

 

 

Institutions

 

Goffman was one of the first people to suggest that institutions may be causing more harm than good.  He introduced a number of concepts including batch living, binary living, the inmate role and the institutional perspective.  He describes patients reacting by withdrawal, open rebellion, colonisation and conversion.  His work was followed up by the work of Barton (1959) who coined the phrase "institutional neurosis". This was a syndrome that he put down to the effects of institutions of low self esteem, withdrawal of interest and inability to plan for the future.  John Wing introduced the concept of secondary handicap and carried out the influential Three Hospital Study. He emphasised the importance of the attitude of others as being a handicap. He believed the main difference between hospitals was dependent upon the staff attitude and that low staff expectations led to depression and indifference in the patients.

 

Social Factors and Mental Illness

 

Farris and Dunham in Chicago in the 1930's were the first to draw attention to the fact that schizophrenia was more common in cities, and in particular in poor inner- city areas, than rural areas. Initially it was believed that the deprivation was in some way responsible for the schizophrenia.  However, the idea of

social drift soon became prominent (e.g. Goldberg and Morrison 1963), and for many years it has been believed that it was schizophrenia drift down the social ladder and into inner-city areas. Recently this idea has been challenged (e.g. Lewis et al 1992) and it has been suggested that deprivation and city life are responsible for the increased incidence of disease.

 

There is a strong association between measures of deprivation and psychiatric admission rates (Thornicroft, 1991). The highest associations are with the rate of drug notification, standard mortality rates and levels of legitimacy. It is not clear whether deprivation just makes it more likely that you are admitted rather than there are higher rates of illness. The usual measures of deprivation are the Jarmen Indices.  These were devised by Brian Jarmen, a GP, and include a number of factors available from census data including rates of unemployment, overcrowding, single-parent families, number of children under five, ethnic groups, elderly living alone, mobility, crime rates and poor housing.

 

Life Experiences

There is a large literature relating psychiatric illness and life experiences. Of particular relevance are:

 

·        childhood separation

·        parental style

·        adverse life events & extreme experiences

·        bereavement

·        expressed emotion

·        unemployment social support

 

The difficulties of researching into this area are separating causation and association, and separating objectivity and subjectivity of life events.

 

Childhood Separation: Fundamental in this field is the work of John Bowlby,and Attachment Theory, in which he postulated that actual or threatened separation of a child from his or her mother results in both immediate distressand causes intrapsychic changes which predispose to depression or in some instances abnormal personality in adulthood. (see Bowlby, 1977). The first part of this theory is not doubted, but whether childhood separation is related to adult depression and personality changes is far less clear, and the research in this area is inconsistent and confusing. Of key importance must be the child's experience following separation e.g. the quality of foster or institutional care.

 

Parental Style: when considering parental style it is vital that the interaction between child and parent is considered i.e. an impulsive child will result in differing parental behaviour than a placid child. (Rutter).

            Bowlby (1977) has described a useful list of pathogenic behaviours in parents:

 

1.         One or both parents being persistently unresponsive to a

child's care eliciting behaviour, or being actively disparaging and rejecting;

 

2.         Discontinuities of parenting, occurring more or less frequently, including periods in hospital or institution;

 

3.         Persistent threats by parents not to love a child , used as a means of controlling him;

 

4.         Threats by parents to abandon the family, used either as a method of discipling the child or as a way of coercing a spouse;

 

5.         Threats by one parent either to desert or even to kill the other, or else to commit suicide (each of these being more common than

might be supposed);

 

6.         Inducing a child to feel guilty by claiming that his behaviour is or will be responsible for the parent's illness or death.

 

Life events: there are considerable methodological difficulties in this area

e.g. retrospective contamination, grading of events, reverse causation (e.g. illness prodromata causing life events) and confounding factors such as personality traits.

 

Finlay Jones (1988) has summarised the evidence for the clinical significance of life events. He concludes that life events are related to the onset of depression, especially mild and moderate depression, suicide and possibly mania. Brown & Harris (1977) described vulnerability factors (loss of mother before the age of 11, not working outside the home, lack of confiding relationship and having three or more children under the age of 15 at home) for depression. This work has been influential, but not replicated in all subsequent studies. Overall there appears to be six to nine times increased risk of clinical depression following life events, but no  difference  between   endogenous/psychotic  pharmacological responsive depression.

 

With regards schizophrenia the evidence that life events precipitate relapse is stronger than evidence that they contribute to onset (Tennant, 1985). There is some evidence of life events prior to anxiety and obsessive compulsive disorder, but no evidence linking alcohol abuse and life events.

5.         Institutional (including those in prisons and h6spitals).

 

It is notoriously difficult to conduct studies on the homeless.  Three major questions remain unanswered:-

 

1.         What proportion of the homeless have a mental illness?

2.         Has de-institutionalisation led to an increase in the number of the homeless?

3.         What services do the homeless mentally ill need and how best can they be provided?

 

There are numerous difficulties in counting the homeless, and homelessness can confuse traditional  measures of psychopathology,  e.g.  suspicion, withdrawal or self care.  Patients discharged from long-stay hospitals appear not to be at particular risk from becoming homeless, but it is less clear whether the younger, never institutionalised, seriously mentally ill are now at an increased risk following the closure of asylums. It is clear that services need to be flexible and mobile and this can be difficult with increasing sectorisation. Mobile treatment teams have been successful in Australia and the USA. Keys to success appear to be perseverance, flexible hours, close liaison with other agencies and offering services such as de-lousing.

 

 

Transcultural Psychiatry

 

The two opposing views of transcultural psychiatry are:

Psychiatric universalist: mental disorders are similar in all cultures

Cultural Determinist: mental disorders show essential differences in different cultures

Specific "culture-bound" disorders include; koro, amok, windigo, Iatah.

 

Migration: Odegaard showed higher rates of schizophrenia in Norwegian immigrants in US in 1932. Since then numerous studies have demonstrated higher rates of mental disorders in a range immigrant groups. The reasons are contentious, but you need to be aware of the following:

 

·     selective vs. causation theories

·     confounding factors e.g. deprivation

·     possibility of mis-diagnosis, or bias in diagnosis

·     differences in service utilisation stress of migration

 

SOCIAL CLASS

 

Registrar general's classification introduced in 1911. Numerous difficulties with classification include; non working mothers, retired, unemployed. It is far from clear what is being measured, and the association between wealth, education, occupation and family background is becoming less clear. Nevertheless people classified as social class V, are twice as likely to die before retirement, twice the neonatal mortality, and have increased rates of virtually all diseases, compared to those in social class I (The Black Report, 1980). Middle class patients have longer consultations with their doctors, and children more "future oriented".

 

SOCIAL ROLES (Parsons)

 

Achievement vs. Ascribed

Functionally specific vs. Diffuse

Particular vs. Universal

In traditional cultures roles more likely to be particular, diffuse and ascriptive.

 

Of particular importance The Sick Role - excused from normal social roles e.g. work, and given sympathy etc. In return expected to seek and accept treatment and get better. The breakdown of this pattern can be described as abnormal illness behaviour (Mechanic, Pilowsky).

 

STIGMA

Attached to certain illnesses, the idea that the victim is to blame e.g. AIDS, STD,  lung  cancer.  Therefore  less deserving  of sympathy~  results in condemnation and anger. Stigma of mental illness reduced by linking to physical illness.

 

THE FAMILY

Numerous models e.g. nuclear vs. extended, reconstituted, single parent, dual worker. Major changes due to: increased divorce1 fewer children1 increased longevity. Only one third of households consist of two parents and dependent children. Important to think of the family as a dynamic structure with changing roles.