Re-locating the sociology of mental health and illness

In the second half of the 20th century sociological analysis has been particularly influential in promoting awareness in two areas – the social patterning of mental “disorders” and the consequences of institutionalization. After the second world war a range of influential studies adopted a “structural” approach to mental health inequalities, such as the community studies of the impact of the environment on mental health conducted in the 1950s and 1960s (Holingshead & Redlich, 1958; Myers & Bean, 1968). These studies suggested links between social conditions and disadvantage (for example, unemployment, poverty and racism) and the genesis of mental health problems. At the same time Andrew Scull's Museums of Madness, a study of the “social organization of insanity” in Victorian England provided a complement to the ground breaking sociology of the underlife of the mental hospital in the US presented by Goffman in Asylums.

Following the demise of the asylum, sociological debates about mental health were not as salient as they had been in the 1960s and 1970s. However, in the last ten years we are seeing something of a revival of interest in sociologically informed analysis in the mental health field (Cook & Wright, 1995; Rogers & Pilgrim, 2005) and there have been a number of novel applications of sociological theory to contemporary issues. For example critical race theory, describing the way in which race is socially constructed across micro and macro levels and how it determines life chances, has been creatively deployed to explore earlier concerns within the sociology of mental health with the social correlates and consequences of mental health (Brown, 2003). The salience of disability theory has been applied to understanding the experiences and post-institutional service arrangements for people labelled with a serious mental illness (Lester & Tritter, 2005) and the rise and popularity of anti-stigma campaigns have been viewed as “interest” work arising from the changing professional role that psychiatry has recently sought for itself (Pilgrim & Rogers, 2005). This re-kindled interest has taken place against a back drop of a number of social trends in the mental health field.

In a post-asylum world there has been a raft of new policy initiatives, attempts at re-configuring therapeutic law related to mental health and a treatment and management transition in the mental health field where a range of eclectic practices and interventions have replaced monolithic institutional provision. This has meant issues of social exclusion and civil society's response to those experiencing mental distress coming more to the fore.

The papers in this special section are an eclectic and rich collection which draws on a range of theoretical perspectives and policy concerns. Four of the papers started life as papers presented at the first annual seminar of the Sociology of Mental Health Study Group of the British Sociological Association's Medical Sociology Group: Sociology of Mental Health, Rethinking the Boundaries, organized by Lydia Lewis and Louise Woodward and held in Nottingham in June 2005.

John Larsen takes as his starting point the increasing demand for service delivery to be based on evidence-based practice. Using a study of a Danish early-intervention psychosis service as an illuminative case study, this paper presents arguments for the adoption of a person-centred ethnographic approach for studying the workings of complex interventions in mental health. The argument unfolds through a presentation of the social science approach to understanding (Verstehen). In the second paper Samuel Leze explores the possibilities for developing a distinctive and vibrant sociology of mental health in France. His argument is set against a backdrop of an ambivalent and haphazard development of a subfield where there has been a tendency to follow an agenda, methods and conceptualization of mainstream psychiatry and sporadic engagement with work from outside the country. In the contemporary era policy initiatives and the status and arrangements for delivering psychotherapy is viewed as an arena ripe for the application of sociological analysis.

In recent years, consumerism and user participation within the NHS has found a particularly strong voice within mental health campaigns, service and policy making. Ewen Speed deploys discourse analysis to narrative accounts from users in order to examine the political connotations of a consumer discourse in the field of mental health. The arguments developed in the paper point to the way in which such a discourse might benefit the state and health professionals more than it does the interests of users.

Notions of Trust in health settings have come under increasing scrutiny in recent years and have been an important focus in discussing encounters with health professionals. Surprisingly perhaps there has been little attention to this in mental health settings. Ivo Vassilev and David Pilgrim explore the various axes of trust relations in mental health services. They argue that the betrayal of trust can be understood as both a normal and abnormal phenomenon in “mental health services” and make the case for an approach which pays close scrutiny to the situated meaning of trust and risk in mental health provision.

Ian Shaw and Sue Taplin take issue with the thesis put forward by Richard Layard that despite the growing richness of societies, we have not become happier. It is argued that the solution put forward by Layard ignores the structural inequalities that contribute to the generation of unhappiness and specifically how these may be dealt with. The authors point to the serious limitations incurred by focusing so much attention on psychotherapy and counselling as a means for solving mental distress rather than the social structural factors which lie at the root cause of unhappiness.

Recent contributions have been made to the sociology of psychiatric knowledge through drawing on the sociology of science and the relationships between psychiatric practice and the state (Manning, 2000). Following on this trend the utility of classification is explored. Drawing on ideas from critical realism, Hugh Middleton and Ian Shaw use three illustrative exemplars to consider the relative merits of differing approaches to “psychiatric” disorders and recent policy initiatives. Their concern is with identifying the benefits of a pluralist approach to mental health research and practice and in particular with exploring the possibilities of a reconciliation of seemingly opposed but possibly complementary roles of medical and social science perspectives. This last contribution flags up the potential for developing new relationships between practiced-based knowledge and sociology. Ideally a sociological approach applied to mental health should benefit both the field of mental health research and practice and the discipline of sociology. In the past there has been a mixed reaction to sociological analysis in the mental health field. Close and mutual working relationships with social psychiatry at one point in time have been replaced by hostility and rejection at others.

More recently there has been more in the way of two-way traffic. Contributions from within primary care medicine, psychiatry and psychology have provided illuminating ways of exploring psycho-social distress in its social context by emphasizing the relevance of using historical analysis, understandings of social processes, social theory and a close attention to the personal accounts of people with mental health problems (Bentall, 2003; Bracken, 2001; Dowrick, 2004; Healy, 1997). The development of sociological reasoning is made richer by the sociological work taking place in other disciplines. However, risks are associated with the incorporation of sociology into other disciplines – for example the picking off of theories which suit or match particular interests and in re-thinking the role and place of a sociology of mental health there is a need to progress an independent and distanced sociology too. This is because ultimately the richness of sociology's contribution to analysis in the mental health arena rests on its ability to challenge and provide diverse and complex understandings of the world together with the richness of its theoretical and methodological approaches.