Preventing mental disorder and promoting mental health: some implications for understanding wellbeing

ABSTRACT

In this paper, I consider the debates surrounding the prevention of mental disorder and the promotion of mental health. In so doing, I offer some provisional insights into the wider notion of wellbeing. All three topics – mental disorder, mental health and wellbeing – imply generative mechanisms of some sort. By considering these mechanisms as ontological entities, we can appraise the relationship between human agency and its biological, social and economic constraints. This provides us with an understanding of bio-psycho-social causal loops, fluxing across time and space, which avoids a reductionist explanation of wellbeing. I also describe how the critical realist concept of four planar social being (our relationship to the natural world, one another, embedding social and economic structures, and our unique biographies) can further assist in the development of a holistic understanding of mental health and mental disorder.

KEYWORDS:

• Mental disorder
• mental health
• wellbeing

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 Exceptions to this meta-rule about social accountability are the interrogations of psychoanalysts and ethnomethodologists, who problematize normality.

2 Despite the weak explanatory coherence of diagnoses of mental disorder, economists such as Layard (2005) relegate poverty as a political priority. He favours the mass availability Cognitive-Behavioural Therapy over social equality (cf. Wilkinson 2005) to improve the mental health of the population. He uses the tautological reasoning that mental illness causes misery, while ignoring the common sense observation that being poor is not usually a recipe for happiness.

3 A sign is a visible empirical indicator to the diagnostician revealed in a physical examination and extended by testing in a pathology laboratory or scanning clinic. A symptom is what the patient reports about their presenting problem. In psychiatry the latter predominate but in other specialities a mixture of signs and symptoms are considered more routinely, which increases the diagnostician’s confidence in discerning what is wrong with the patient (Pilgrim 2018).

4 A good chunk of the contestation about psychiatric knowledge has been in relation to the dominant role of eugenically-driven reasoning at the end of the 19th century, championed in particular by the German psychopathologist Emil Kraepelin (Pilgrim 2008). Today this is called ‘neo-Kraepelinian’, ‘biomedical’ or ‘bio-reductionist’ psychiatry. Alternative important strands competing within the profession have come from psychoanalysis (following Sigmund Freud) and social psychiatry (following Adolf Meyer). This tension between the competing groups within the US psychiatric profession has been reflected over the years as DSM has been revised (Bayer and Spitzer 1985; Wilson 1993).

5 The biopsychosocial model encourages us to consider multi-factorial causality, but does not necessitate a critique of diagnostic labels left over from psychiatric positivism.

6 Mental illness is basically, like all illness, a form of deviance; it reflects impairments in fulfilling role expectations and our willingness or ability to follow rules. Mental health professionals inter alia are rule enforcers (Bean 1986). For this reason, sociologists talk of ‘emotion rules’ and describe mental disorder as a form of ‘residual deviance’ to separate it from criminality, warranting versions of formal or informal social control (Scheff 1966; Thoits 1985; Hochschild 1979).

7 The ‘managed heart’ of a retailer is part of keeping us on the ‘hedonic treadmill’ of consumption, as a promised path to happiness: ‘hello, how are you?-what can I get for you?-anything else?-have a nice day-missing you already’ (repeat unendingly) (see Hochschild 1983).

8 The term ‘stress’ has become ambiguous in the vernacular, with both inner and an outer points of reference.

9 Etiological specificity is one criterion of a good medical diagnosis. By definition, functional diagnoses are judged by conduct in context, not biological markers, and they have no known causes. Thus PTSD is unusual in its specific inclusion of a causal antecedent.

10 The dominant picture in dementia is a marked deterioration in short term memory and problems of orientation in time and space. However, there can be personality changes as well, for example when the frontal lobes of the brain are affected, making the patient disinhibited.

11 One helpful option here might be the Power Threat Meaning Framework (Johnstone et al. 2018).

12 This realist description can be compared to critical ‘fat studies’ from a constructivist tradition in social science. See, for example, Cameron and Russell (2017)

13 Although we are not only what we eat (the classic example of reductionism), gut bacteria can indeed affect neuro-endocrine functioning, with psychological consequences (Rieder et al. 2017).

14 During the Second World War the UK population showed an improvement in its nutrition and food standards also improved.

Additional information

Notes on contributors

David Pilgrim

David Pilgrim is Honorary Professor of Health and Social Policy, University of Liverpool and Visiting Professor of Clinical Psychology, University of Southampton. His books include Critical Realism for Psychologists (2020) and Understanding Mental Health: A Critical Realist Exploration (2015), published by Routledge. He is currently writing a book on identity politics.