Why is social psychiatry still alive?

Some readers might be surprised when reading the title of this editorial. They are either convinced that ‘psychiatry is social psychiatry, otherwise it is not psychiatry’ as it was put some 30 years ago in Germany, or they think that social psychiatry is a term that was established in the past century and no longer needed after having restructured mental healthcare provision, i.e. after implementing community mental health services and downsizing or closing the large asylums in most part of the western world. Still others associate social psychiatry with mental health services research or confound it with ‘social romanticism’. Finally, there are some who think that social psychiatry is no longer ‘fancy’ and should be replaced by ‘psychiatric epidemiology’ as–especially with its access to sophisticated statistical methods–this is becoming one of the promising fields in this area.

Before answering whether social psychiatry is still alive or dead already, we have to approach the question of what social psychiatry really is about. Although it simply modifies the word psychiatry, the ambiguity of the word ‘social’ is troubling this question (Priebe & Finzen, [2002]). Social can be defined as ‘relating to human society, its kind of organization and the interaction of the individual and the group’. As a consequence, social psychiatry is the branch of psychiatry that focuses on the interaction between mental well-being, mental illness and the environment. As such, it is focusing on the social dimensions of mental health, mental illness and mental healthcare (Priebe & Finzen, [2002]). As every branch in medicine offers a theoretical background, scientific evidence and treatment options, thus, social psychiatry has a conceptual framework, based on theory and research, as well as techniques of how to prevent, treat and care for people with mental illness.

If we adhere to the above said, social psychiatry covers a wide field of different topics ranging from a societal or cultural perspective on mental health to a focus on individual aspects of metal disorders. Sociological areas include the influence of culture, society or social structures, brief of ‘the environment’, on the individual who suffers from mental illness. As such, research into the relationship of mental disorders with migration and urbanization, social integration and exclusion, e.g. attitudes towards people with mental illness and the resulting stigmatization and discrimination, respectively, can be subsumed here. It further includes mental health services research, mental health economics and psychiatric epidemiology. After an extensive period of research into deinstitutionalization and its consequences, it has been questioned recently whether deinstitutionalization has already led to a hidden and partial reinstitutionalization (Priebe et al., [2008]). Along with higher life expectancy of people with mental illness and their increased comorbidity, changing family structures and, in a wider context, societal changes may have an enormous impact on the needs, development and provision of mental health services in the future. Public mental health might be best summarizing this part of social psychiatry.

Beyond public mental health, social psychiatry is as well (and often exclusively associated with) studying the interaction between an individual, social circumstances of this individual and the respective implications on mental well-being. One of its focuses here is research into therapy and treatment. This includes both acute and stable illness phases of psychiatric disorders which tend to become chronic in some cases. Communication between individuals, for instance in a therapeutic context, as well as the question how mental health professionals and their attitudes influence the treatment process, are studied. Questions on how to best intervene to prevent relapse or to increase the quality of life of those affected are both elements in this part of social psychiatry, as is early intervention. A variety of psychological interventions, from cognitive behavioural therapy to supportive psychotherapy, has been evaluated. Finally, involving users and carers in service planning, evaluation, research and development is essential to this part of social psychiatry. Thus, social psychiatry is not just taking care of chronic people, but also adds to the knowledge on how to care for people in their first illness episode or during a relapse.

While therapy and treatment are more focused on classical medical/psychiatric areas, a third part of social psychiatry, psychiatric rehabilitation, is combining medical and social approaches to explore the consequences of mental illnesses, e.g. regarding employment, housing, physical health, social interaction and significant others. Psychiatric rehabilitation has no clearly defined boundaries to therapy and treatment, but develops it into social aspects and introduces a more long-term perspective with resilience and recovery being leading principles here. Thus, social psychiatry encompasses a wide spectrum from public mental health over acute treatment of people with mental illness to rehabilitation and recovery of these people. This implies that social psychiatry is not identical with ‘community psychiatry’ as the latter is just defining where the therapy takes place, but does not go beyond that.

Due to the complexity of the people treated, mental healthcare thought to find a solution in replacing the traditional staff comprising psychiatrists and mental health nurses by ‘multidisciplinary teams’. These involve different specialists, be they responsible for employment, housing, specific psychological interventions, social care, etc. However, these more and more specialized and fragmented teams are faced with the advantages and disadvantages of assessments deriving from different (professional) backgrounds. Contrary to the original idea to provide better and more appropriate treatment and care to patients in different stages of their illness, services often fail to properly engage in treatment and care as they are just responsible for a short illness period. Handing over patients in time and without losing information to the next team in charge have become more and more regular. Thus, too diversified, hyperspecialized teams often are not in the best interest of the patient as the chain of treatment is disrupted or interrupted.

Research in social psychiatry is outlined along the above mentioned topics, and thus covers a wide range of fields. It includes public mental health with its branches epidemiology, mental health services research and research into social inclusion. It further consists of therapy and intervention research. This last element also covers evaluations of complex interventions. Finally, research into consequences of mental illness, e.g., vocational reintegration or physical health, is part of social psychiatry. However, the number of topics alone is not sufficient to guarantee the survival of social psychiatry. It is no longer enough to only focus on epidemiology or mental health services research. This might astonish some readers, but social psychiatry has to broaden its boundaries. Integrating other and new techniques is now on the agenda of social psychiatry. We have to ask ourselves what and how other research and clinical fields, e.g. neuropsychology, neurophysiology or neuroimaging, might lead to a better understanding of the people we are caring for and help improve their treatment, their outcome and, finally, their lives. Psychopharmacology, different forms of psychotherapy and various psychosocial interventions had and have a great impact on these people. However, this alone is not enough to successfully tackle these people's deficits that are responsible for the barriers between ‘them’ and ‘us’. Better and in-depth knowledge and understanding of neurocognition and social cognition, of its respective functioning and of underlying neuronal networks should not be left to neuroscientists and their agenda, but must become part of research in social psychiatry. In the end, social psychiatry will be faced with translating this new knowledge into routine care. Thus, it is vital for the field not to lose contact to neuroscience and, where this is not the case, to rebuild it quickly.

Why is social psychiatry still alive?s It is alive because there is a wide range of topics for social psychiatry to cover and there are still questions to be answered. However, if social psychiatry is to develop, it has to take a step forward and include other research questions and methods. Its strengths of integrating different aspects into a ‘holistic view’ should not be fragmented, but developed. Its integration in medicine should not be questioned, but is a clear strength, as only psychiatrists with their skills are able to treat people with mental illnesses in a ‘holistic’ way.

This issue of the International Review of Psychiatry allows the opportunity to publish a series of papers that give an excellent overview of what social psychiatry is today. These papers all contributed to a symposium in honour of Wulf Rössler, a renowned and world-class social psychiatrist and the Director of the Psychiatric University Hospital in Zurich, Switzerland. He started this scientific work seemingly far away from social psychiatry, with a paper on ‘Cognitive disorders in schizophrenics viewed from the attribution theory’ (Rössler & Lackus, [1986]). Soon after that, his research shifted to ‘proper’ social psychiatry with publications on mental health service provisions and related aspects. However, over the last few years, he and his research group broadened their views of social psychiatry again by tying in with the very first paper and its background of social cognition. We are looking forward to reading more in the years to come.

Ad multos annos (to social psychiatry and to Wulf Rössler, of course)!