|Year : 2016 | Volume
| Issue : 3 | Page : 181-184
Social psychiatry in a rapidly changing world
Thomas K. J. Craig
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
|Date of Web Publication||3-Nov-2016|
Thomas K. J. Craig
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, DeCrespigny Park, London SE5 8AF
Source of Support: None, Conflict of Interest: None
Many societies around the world are experiencing a period of unprecedented change in traditional social roles and customs. Globalisation has contributed to materialism and a me-first individualism that heightens awareness of income inequality that itself is one of the most robust markers of unhappiness in society. Ever increasing urbanisation has driven an erosion of large ‘joint’ family arrangements to be replaced by smaller and relatively isolated nuclear families and single parent living. Mass migration has unmasked deep seated fear and prejudice towards the outsider in society. These global changes are fertile ground for the social conditions that have long been known to be risks for mental illness – poverty, poor quality child care, social isolation and the active discrimination and exclusion of the alien, the physically disabled and mentally ill. While there is little we can do to reverse global change, there is much a social psychiatrist can do to mitigate the effect, ensuring his/her voice is added to other calls for reducing discriminatory practice, promoting evidence-based social interventions such as parenting advice and peer support and ensuring that the success of a treatment is measured not just in terms of symptomatic improvement but in whether it results in an outcome that is valued by the patient.
Keywords: society, psychosis, common mental disorder, childhood
|How to cite this article:|
Craig TK. Social psychiatry in a rapidly changing world. Indian J Soc Psychiatry 2016;32:181-4
The theme of this 22nd World Congress of Social Psychiatry is that of change. Change for the best, change for the worst, and hopefully not change for change sake. It is typically resisted by the old and welcomed by the young. Most would agree that the speed of change is accelerating, driven by new digital technologies that have made the world feel smaller through faster and wider communication spreading knowledge as well as shaping and driving consumerism. One consequence on India and much of the world has been the erosion of centuries old traditional values with the movement from collectivism toward individualism reflected in an emphasis on personal choice, smaller nuclear families, greater urbanization as well as sharpening the awareness of income inequality that itself is a key driver for social unrest and change. Many of these wider environmental and cultural impacts bring changes in how people relate to each other. For example, the move toward individualism emphasizes personal goals and at the extreme a “me first” attitude in contrast to interdependent, cooperative, and “we first” mores of the collective society. Child rearing is increasingly the business of the parent, less the grand-parent, and still less a wider community; people in urban dwelling live in greater isolation from their neighbors even though geographical proximity may be greater. This all has tremendous bearing on psychiatry not least because so much of mental illness is defined and determined by the quantity and quality of interpersonal relationships.
That poverty and social exclusion is bad for mental health is eloquently shown at a country level by the almost straight line relationship between the scale of income inequality in a country and the prevalence of mental illness.The United Kingdom and the United States are unfortunate examples of this association where there is evidence that the inequality gap may be growing. In England, in 2012, a survey of poverty and social exclusion found 4 million children to be experiencing multiple deprivation, 13 million adults living in substandard housing, 4 million in “food poverty,” and a third overall were below nationally accepted minimum standards—double the rate of 1983. At the same time, the number of “super-rich” in the south of England and in London, in particular, continued to grow with very little outward sign of the recession that decimated the economy of towns in the industrial north. The situation in India may be even more dramatic where, despite having highest economic growth rates in the world, there is also pervasive poverty with a greater share of the world’s poorest than it had 30 years ago. The impact of such poverty and inequality on children is particularly noteworthy given that we now know that the basis for mental ill health in adulthood is largely determined not only by childhood experience of poor nutrition, maternal depression, and parental neglect but also by the antenatal impact of toxic substances including alcohol and obstetric complications, all of which are more prevalent in poor and multiply disadvantaged families.
Neglect and abuse in childhood is now a firmly established causal risk factor for most mental illness in adulthood including major depression and psychotic disorders including schizophrenia. The prevalence of abuse clearly varies by how tightly it is defined, but the results of a recent household survey of 1,761 young adults in England is typical, reporting rates of 11.5% for physical abuse resulting in injury, 11.3% contact sexual abuse, and 16% severe neglect. Of course it is not just in the home, as protracted bullying from peers at school and increasingly via social media has adverse effects that can persist long into adulthood. It is arguable that abusive experiences are easier to hide in individualistic societies where so much family business is carried out behind closed doors outside the scrutiny of neighbors and wider family who in any case have long been dissuaded from interfering in other people’s business. With the advent of social media, bullying does not stop at the school gate either.
The pathways from trauma in childhood to adult mental illness have been elaborated for some conditions. For example, in major depression, a history of significant childhood maltreatment has been shown to be associated with enduring low self-esteem on the one hand and with an increased risk of later social and interpersonal difficulties on the other. Young women who have been maltreated in childhood more often end up in unsupportive and injurious relationships that in turn throw off severe life events and difficulties that are known to precipitate depression, while also lacking supportive parental and wider family and friendship ties that might mitigate the worst impact of these events. Considered crudely, the abused child enters a “conveyor belt” of adversity across childhood, adolescence, and early adulthood from which it is very difficult to escape as the chances to attain and retain close trusting relationships are missed or spoiled.
It is also apparent that severe breakdown of the society, for example in war,environmental catastrophes, and other conditions leading to forced migration is bad for mental health. A comprehensive meta-analysis, carried out even before the current crises in the middle east, showed prevalence of PTSD among forced migrants of 30.5/10,000 and 30.8 for depression. According to the UNHCR, by the middle of 2015 there were 20.2 million refugees worldwide, up to 78% over the comparable period a year previously. A majority of these refugees were hosted in developing countries that can least afford the massive influx of mouths to feed. The causes of mental ill health among refugees lie in a multitude of traumatic experiences including death and separation from the family and other support and the trauma of the events themselves including torture the effects of which is often long-lasting. But it is all too easy to forget that in addition to whatever traumas may have been experienced in the home country, much of the risk of mental ill health lies in the nature of the reception given to migrants in the host country.
One of the most striking findings in research into the causes of schizophrenia and other psychoses in Europe is the repeated observation of a higher incidence among migrants compared to the indigenous population and the fact that this higher incidence is not seen in the migrants’ home countries. This discrepancy in incidence persists across generations suggesting it cannot be explained solely by migration but must represent ongoing, probably discriminatory experiences in the host country.Furthermore, it turns out that the risk is greatest for these people where they reside in areas where they are in greatest minority and is least when living in neighborhoods that have a high density of people who share their minority ethnic status.  There is no evidence that this increased risk is due to differential rates of biological factors such as perinatal obstetric complications, nor does it seem to be due to differences in the use of psychoactive substances. Instead, the evidence points toward social causation with links to stressful life events reflecting the widely held belief in the black community that they are more exposed to discriminatory stressors such as being stopped and searched by police while minding their own business in the community.
So it seems fairly clear that in one form or another, abusive social interactions lie at the heart of much mental illness. One response to onslaught is withdrawal so that it comes as little surprise that living alone and social isolation are more commonly reported by people who develop a first episode of psychosis. The lack of confidants and supportive friendships more commonly reported by people who suffer from depression and loneliness (the subjective expression of isolation) is associated with many physical and mental illnesses. In one large epidemiological study, for example, after controlling for age, gender, socioeconomic status, and prior ill health, subjective loneliness was associated with a 14% higher risk of premature death and with persistent insomnia, depression, and suicidal ideation. People with established psychosis continue to experience isolation of course, compounded by the consequences of illness and societal rejection. Stigma and discrimination remain a major challenge for psychiatry and as ever, feature prominently in this congress. Just a few facts drive the point home: fewer people suffering from schizophrenia in Britain are in work today than were in the 1960s, reflecting a marked reduction in sheltered workplaces, day centers, and support centers, typically closed not only for economic reasons but also in the flawed belief that the benefits they offered in terms of social contact and purpose to life were outweighed by their contribution to dependence and institutionalization. In the meantime, survey after survey continues to show enduring discrimination present even among mental health staff. The continued reliance on coercive treatments is a global challenge. A greater proportion of patients in England and Wales are admitted to hospital compulsorily now than they were a decade ago, and the majority of acute admission wards that were formerly open are now locked again. According to one recent review from the United Sates, while the absolute numbers of people suffering from severe mental illness is much the same as it was 100 years ago, the ratio of incarceration in prison to admission to hospital has inverted from 25% in penal institutions and 75% in hospital to 95% in prison and just 5% in hospital.
| What Social Psychiatrists Can Do|| |
While preventing and responding to adverse social conditions including poverty, war, and natural disasters is more clearly the job of politicians than psychiatrists, there is clearly a place for national psychiatric associations and even individual psychiatrists to get involved lending his/her expertise where appropriate. It is a remarkable fact that many political and commercial leaders continue to deny the scale of the impact that mental disorders have on the welfare and productivity of their subjects and employees. At the very least, psychiatrists should be adding their voice to the wider medical, social justice, and media outlets to call for reducing the social inequalities that research has repeatedly shown to be significant causes of all illness including psychiatric disorder and hence economic and social burden to the society.
We do not have to wait for a full understanding of the mechanisms linking early experience to adult mental illness in order to know that doing something about child abuse and bullying would be a good thing to do. Direct parenting advice and training to families with a history of mental illness can reduce the risk of mental and behavioral disorders in children by as much as 40%, and there is abundant evidence demonstrating the efficacy of parenting interventions in childhood conduct disorders, with several well-validated and manualized approaches in clinics and schools. ,,
Of course, confronting and eradicating abuse should start with the way psychiatrists and the wider mental health services deliver care to their patients.Coercive practices need to be challenged vigorously. It may be the case that some coercion will always be necessary for the management of severe mental illness in order to protect the individual or wider society, but the only sensible response is to regard all coercion as undesirable and to work and research toward the delivery of treatment in ways more acceptable to our patients.This goes beyond simply stamping out abusive practice when we see it. It means also questioning the appropriateness and acceptability of our own behavior and how we interact with our patients and their families. In many parts of the world, the result has been an increasing recognition that clinicians need to be more sensitive to the goals and aspirations of their patients and less paternalistic in their approach. Providing symptomatic relief is still important but it is just a start and not sufficient if the sufferer remains in the same stigmatized, unemployed, and disempowered state that they were when they first sought help. This calls for changes in the low expectations many health professionals have for what their patients can achieve. A good place to start are the writings on personal recovery that have had a considerable influence on mental health care in many countries around the world, showing how patients can lead fulfilling lives despite continued illness. For example, research has clearly established that many people who have experienced severe mental illness wish to return to employment and there is now abundant evidence that many can do so given appropriate support, yet one of the significant barriers to this outcome lies in the over-cautious attitudes of clinical staff. Richard Warner in his excellent treatise on the impact of the social economy on recovery in schizophrenia elegantly demonstrated how recovery rates went up and down in parallel with the economic cycle and in tune with more or less pessimism on the part of psychiatrists (itself mirroring the same economic cycle). The key link to this association was employment and status opportunities for the patients over and above any innovation in pharmacological or psychological treatment.
In addition to stamping out abusive practices and liberating choice, another key target of socially orientated mental health care should be efforts to reduce loneliness and isolation. All people benefit from activities with other people that match their interests and abilities. Meta-analyses of social programmes for elderly populations clearly demonstrate substantial reductions in depression, improved subjective quality of life, and life satisfaction.  Peer support interventions show comparable benefit to formal psychotherapy (CBT) for moderately severe disorders while the benefits of Clubhouse programmes for severe mental illness in adults have been shown to be mediated by the sense of belonging and of being valued by others.
In conclusion, as amply demonstrated through symposia, papers, and posters of this congress, there is no shortage of work for the social psychiatrist. But it does mean getting out of our comfort zone to become more widely involved with colleagues outside of psychiatry to ensure the appropriate emphasis is placed on facilitating and enhancing the ordinary activities of everyday life that are so important to all people.
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Conflicts of interests
There are no conflicts of interest to declare.
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