Forward to Dr Emma Farrell’s forthcoming book ‘Making Sense of Mental Health: A Practical Approach Through Lived Experience’ (The Liffey Press, September 2022) by Dr Pat Bracken Independent Consultant Psychiatrist
The world of mental health work is messy through and through. There is no agreed understanding of where mental health problems come from and even, as Emma Farrell points out early on, no agreement about what words we should use to talk about them. And yet, for those struggling in the midst of a mental health crisis there is often a desperate need for clarity and certainty so that a path forward can be charted. Mental health work is always about an attempt to help the person struggling to find hope. It involves nurturing a sense that things can get better. A first step often involves working with them to find words to describe what is happening and helping them to articulate the nature of their strengths as well the nature of the obstacles they face. While this sounds straightforward, Farrell shows us very clearly that it is not. This is because the words we use carry weight; they are never neutral. Their meanings derive from the assumptive framework in which they are used and this is always determined by interests of one sort or another. Words matter. This crucial insight lies at the heart of this book. Farrell provides a rich account of the complex reality of mental suffering from the vantage point of the people who are suffering. Her work is both deeply philosophical and yet, at the same time, easily accessible. Therein lies its importance. This is a book that will speak to a wide audience: academics and professionals as well as service users and their families.
Currently, the vocabulary used most often across the world to frame mental suffering is a medical one. Distress is simply about symptoms of mental illnesses. People are advised that they need a diagnosis, and psychopharmacology is the dominant response. While some people can get better within the vocabulary of this framework, many do not. In fact, people often find it disempowering. While some find the standard menu of medication plus a little added CBT helpful, many need to find other pathways towards recovery. The problem is that the medical framework is dominant everywhere, and a narrow symptom-based vocabulary has become the lingua franca of mental health across the globe. As a recent UN Special Rapporteur, Dainius Pūras, writes: ‘the field of mental health continues to be over-medicalized and the reductionist biomedical model, with support from psychiatry and the pharmaceutical industry, dominates clinical practice, policy, research agendas, medical education and investment in mental health around the world’ (1).
This biomedical approach inserts a powerful set of images, assumptions, metaphors and narratives into the life of the struggling person and their family and supporters. We are effectively shaping how they will think about what is happening to them and how they might find a way forward. Once a person starts to frame their own suffering in terms of symptoms, illness, diagnosis and treatment they are automatically thinking about solutions that emerge from medical expertise. Pūras goes on to say that: ‘We have been sold a myth that the best solutions for addressing mental health challenges are medications and other biomedical interventions’ (1). In this framework, the medical practitioner becomes the authority and the person suffering becomes the ‘patient’, whose only task is to take the prescribed treatments.
Emma Farrell provides us with a straightforward guide to the models employed in mental health work and provides an important set of concepts to help us get beyond the grip of the biomedical paradigm. Chief among these is the idea of hermeneutics. This is not a word often used in training courses for doctors, nurses, social workers or therapists. However, as Farrell demonstrates very clearly, the current philosophy of reductionism and positivism that dominates mental health research, training and theory-making has proved to be completely inadequate when it comes to mental suffering. This philosophy, which has underscored attempts to understand the mental world in terms of causal processes (neurological or psychological) has never been a good match for the sheer ‘messiness’ of what is involved in states of madness, distress and dislocation. Our attempts to force this messiness to conform - to present itself in a way that would allow us to map it and produce a predictive science - have led to a great deal of wasted research resources and many therapeutic disasters.
In contrast to reductionism and positivism, hermeneutics is based on the idea that the world of the mind is a world of meanings that can only be grasped in relation to the social, cultural and political context in which such meanings are situated. In turn, this social context is not reducible to a set of ‘factors’ that can be related to one another in an idiom of causal laws. The assumptions, values, priorities, roles, stories, images, examples and norms through which we live our lives are historically and culturally contingent. They are unstable, and while we can seek to understand how they develop, interact and impact upon our lives, quantitative forms of science do not get us very far along this road. Meaning emerges for us linguistically and symbolically. Biomedical reductionism, and traditional forms of cognitive psychology that characterise our inner worlds in terms of ‘information processing’, misrepresent the reality of how we live and make sense of ourselves and our worlds. It is like trying to under the play Hamlet by counting the number of words and sentences that Shakespeare has used to write it.
The most important development in the field of mental health in the past 40 years has been the growth of the international service user movement. For the first time ever, the voices of those who use struggle with states of madness and distress are being heard and are starting to be taken seriously by those who plan and fund services. The WHO, in its revolutionary new Guidance on Community Mental Health Services says that: “it is critical that mental health systems and services widen their focus beyond the biomedical model to also include a more holistic approach that considers all aspects of a person’s life” (2). It goes on to say that: “There is increasing recognition that people with lived experience, due to their own knowledge and experience in the area, have an important contribution to make and a central role to play in the design, development, improvement or transformation of mental health services, as well as in supporting and delivering direct services to others such as peer specialist, peer support and peer-run crisis services” (2). This is a very different role to that prescribed for the ‘patient’ by the biomedical approach.
I believe that this move by the WHO, away from supporting only professional and medically-informed solutions of mental health problems, is vitally important (3). However, if we are genuinely to hear the voices of service users in all their diversity we must develop more open, transparent, democratic and reflective approaches to knowledge production. As long as medical science and positivist forms of psychology continue to be considered as providing privileged access to the truths of mental illness this will not happen. We need a hermeneutic approach, and Farrell provides us with a brilliant introduction.
Farrell challenges us to embrace the messy reality of mental health problems rather than force this complex world into the parameters of a single model or framework. Her book, centred on the voices of people who struggle with mental health problems, is essentially an invitation to sit with the contradictions, the difficulties and the ambiguities of mental health work. Enjoy.
1. Pūras, D. (2017) Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health. Geneva: United Nations, Human Rights Council; (A/HRC/35/21). (https://undocs.org/A/HRC/35/21, accessed 22 May 2022)
2. World Health Organisation (2021). Guidance on community mental health services: promoting person-centred and rights-based approaches. https://www.who.int/publications/i/item/guidance-and-technical-packages-on-community-mental-health-services
3. Bergner, D (2022) Doctors gave her antipsychotics. She decided to live with the voices. The New York Times, May 17th 2022. Available at: https://www.nytimes.com/2022/05/17/magazine/antipsychotic-medications-mental-health.html#commentsContainer