Mental health and biomedical neoliberalism: can creativity make space for social justice?

ABSTRACT

In this article, we introduce a creative assessment task developed for postgraduate social work students studying critical perspectives on mental health. We discuss how moving beyond the constraints of text-based assignments generates space for students to explore new ways of thinking about mental health, beyond the limitations of dominant illness-based understandings. Through creativity, the task enables an exploration of social justice in practice, reflexivity, humility, complexity, and multiplicity. Students learn about the value of lived and embodied experience knowledges and the task generates opportunities for paradigm shifts away from biomedical discourses. We argue that the task is itself a subversion of neoliberal knowledge production within a tertiary education context.

KEYWORDS:

• Mental health
• higher education
• social work
• creativity
• critical theories

Introduction

Mental health social work is a highly contested terrain, wherein social work educators are required to navigate the dominance of biomedical knowledge and the significant impacts of neoliberalism on social work practice. Biomedical neoliberalism leads to an understanding of distress that is primarily focused on identifying bio-genetic causes and diagnosing and treating ‘symptoms’ within ‘individuals’. The focus of biomedical neoliberalism on standardization of practice and economic efficiency has been critiqued, as it obscures social contexts, reducing the kinds of meanings that are seen as legitimate for understanding and responding to emotional suffering and difference (Read & Harper, 2022). Pushing against the grain of the dominant illness-based approach, critical mental health education requires attention to the social, cultural and political determinants of mental distress and diverse knowledges and practices. Critical mental health education challenges the harm caused by dominant colonial and Eurocentric perspectives that adopt individualistic and diagnostic approaches to mental health and that situate distress as ‘illness’ while ignoring socio-political contexts. A critical perspective questions the construction of mental health as a matter of individual responsibility, and challenges the use of coercion when a person does not ‘comply’ with prescribed treatments, or when such treatments are ineffective. For social workers, a critical approach is necessary in the ongoing development of rights-based mental health practice, addressing the harmful impacts of pathologisation and coercion (Tseris et al., 2022).

There are numerous challenges that we seek to address in our teaching:

• Critical perspectives on mental health are marginal, even within social work, which is influenced by the pervasive, Eurocentric (white, colonial, individualistic) illness model. Students need to bring an openness to new perspectives and to unlearning taken-for-granted assumptions about mental distress and difference.

• There can be a disconnect between social justice rhetoric and practice, leading to certainty in response to complex experiences, or alternatively, a sense of powerlessness in response to biomedical thinking and the impacts of neoliberal policy in practice settings.

• There is a need to center lived experience knowledges in non-tokenistic ways (Daya et al., 2020), while also challenging an artificial separation between ‘professionals’ and ‘clients’, in order to critique othering practices.

• We aim to instill a curiosity about multiple lived experience knowledges, and diverse perspectives on the current system, to discourage certainty, reductionism, or rigid thinking about the ‘correct’ approach.

The assessment task presented in this article is one example of how we work toward this aim, designed for postgraduate social work students studying critical perspectives on mental health. Students are asked to create a visual representation of their preexisting understandings of mental health, the discourses and assumptions that have informed their views and experiences, and their current learning goals.

Background- critical pedagogies and strategies beyond text

Social work is defined by the aim to ‘promote social change and development, social cohesion, and the empowerment and liberation of people’ (International Federations of Social Workers [IFSW], 2014). Located in the settler colonial state of Australia, a social justice priority and necessity in our teaching is to engage students in processes where they can learn about and subvert the interconnections of social work power and the ongoing dominance of white colonial epistemology, models and methods (Walter et al., 2011; Yassine & Tseris, 2022). This involves teaching methods that develop critical consciousness, including skills in critical reflection on our own positionality, worldview (identity, values, knowledge) and privilege, as these provide the lens through which we identify oppressive forces, make decisions and take action (Terare, 2019).

Drawing on Marcuse’s theory of aesthetics, scholarship in critical social work pedagogies has drawn attention to the limitations of language as a tool for generating space for knowledge and activism that challenges the status quo, underlining that language is politically bound, reductive, and utilized by dominant groups to reinforce systems that serve their interests (Barak, 2020). For example, the literature shows how ‘trauma-informed practice’ has been co-opted by medicine, integrated into mental health service provision in ways that further pathologise distress and justify the use of professional intervention whilst diminishing the activist origins of this paradigm, including the call to focus on the socio-political causes of distress (Tseris, 2018). Social workers have raised the question of whether co-production of mental health curriculum and research to include the narratives of persons with lived experience is in fact co-option of their stories (Sapouna, 2021).

Moreover, language is part of the context in which our social identities, values and knowledges are formed, and thus a limited tool for interrogating our own belief system and dominant paradigms to develop critical consciousness and create space to see and feel things in new ways. In this context, art, or the aesthetic dimension, as opposed to language/text, is an important space from which different questions and knowledge can emerge because it elicits separation from institutional practices and everyday experiences, resulting in new perspectives and ideas (Brookfield, 2002). Arts based methods have been used successfully in social work education to make links between micro and macro dimensions of experience, to explore affect and empathy, to identify the impact of oppression, and to facilitate deeper theoretical analysis and critical thinking in student reflections (Leonard et al., 2018; Walton, 2012).

In our teaching of critical perspectives on mental health, to Master of Social Work (Qualifying) students within an Australian university setting, art has provided an important dimension for learning alongside the use of text. The curriculum includes analysis of language/power in the form of diagnostic labeling of human distress as a tool of racialized and gendered oppression, and opportunities for students to critically reflect on the knowledge they bring to their studies. The aesthetic dimension, whilst still connected to individual worldview and not impervious to the influence of dominant knowledges, offers students an alternative mode for the expression of ideas, which facilitates exploration of the social-political context of mental health discourse and practices based on embodied experience (Huss, 2012; Segal-Engelchin et al., 2020).

A creative assessment

We developed an assignment that asks students to represent multiple paradigms of mental distress through a creative process. In the task, students are required to produce a visual piece that explores the diverse influences on their current understandings of mental health and distress. They are encouraged to consider the impacts of first-person (experiential) knowledge of distress or interactions with mental health services, current/previous professional roles, diverse cultural and spiritual perspectives on experiences that are deemed ‘illness’ within a Western framework, media representations of mental health, and any other influences on their current understandings. They are also required to explore current gaps in their knowledge and how they would like to address these. The task is supported by readings, which introduce key principles relating to critical perspectives on mental health. The learning objective that underpins the task is: ‘critically reflect on your experience and knowledge of the mental health field, and identify areas for future development.’

The creative assessment was developed in 2018 and has been part of the curriculum annually since then, with at least 25 students in each cohort. We have found the creative assessment task to be highly valuable in supporting students to move beyond an intellectual engagement with social justice issues in mental health, toward an engagement with complexity, uncertainty, and multiple paradigms for making sense of mental distress. This is an important invitation for students to consider how they might apply sociological knowledge within social work practice, reducing theory-practice gaps. The task also asks students to consider diverse forms of knowledge on mental health, including lived experience knowledges, with creative practices inviting humility, playfulness, curiosity. For students in the MSWQ program, such engagement is extremely important, because a large proportion of students have only been exposed to scientific and biomedical perspectives on mental health before completing the course.

Students have engaged in a range of creative practices in the task, including collage, drawing, painting, photographs, and even sculpture. We do not place limitations on the mode of visual expression. Students write a short description of their creative work, but the written piece is de-centered and acts only as a complementary piece to the creative component. In our view, the assignment offers a rich learning experience, which makes space for hopeful and nuanced understandings of distress, extending beyond the constraints of a biomedical perspective. Below, we outline some outcomes of the task, drawing on our observations and feedback from students.

Reflections on the outcomes of the creative task

Engaging with critical perspectives and unlearning

In exploring their understandings of mental health/distress with attention to context, students engage with the concepts of constructivism, subjectivity, support, and complexity. Drawing on their own experiences, students consider how their understandings of mental health/distress intersect with their relationships, emotions, social and cultural norms, social structures, privilege, and dominant discourses that pathologise distress as an individual problem. In doing so, some students reflect on their own and/or others’ uncritical ascription to the biomedical construct of mental distress as a signification of privilege, and how this reproduces power relations that maintain injustice. First Nation students’ work centers First Nations worldviews on health/wellbeing and shows the importance of non-Indigenous social workers not assuming that dominant paradigms have a marginalizing effect. Such contributions demonstrate that First Nations knowledges are not marginal or oppressed, nor ‘other’ to Western epistemology. In this way, students begin to depart from the notion of a singular universal truth about mental health/distress and that ‘clinical work’ is de-politicized. Students also consider how neoliberalism reinforces the biomedical paradigm through the marketization of health as an individual consumer ‘choice’. In recognizing the context of mental health/distress in this way, there is a realization amongst students, some for the first time, that there are multiple understandings of distress and that mental health is complex- experienced culturally, politically and personally. Moreover, within services and society more broadly, not everyone is afforded the resources, safety and support to enable their wellbeing as they define it. Outcomes of this include that students see how their knowledge is partial and that positionality and privilege connect to mental health. This can lead students to new ideas about individual and collective responsibility for mental health, and the role of social work in mental health services and beyond. This in turn creates an opportunity for us as educators to engage in dialogue with students about upholding the value of social justice in social work practice by positioning oneself as a learner (not a ‘clinical expert’), making space for multiplicity and complexity.

Moving beyond social justice rhetoric

We have found that the creative process pushes students toward a deeper understanding of what social justice practice can look like in mental health contexts. Notably, experimenting with visual representations is helpful in encouraging an exploration of complexities and nuance, rather than the adoption of a binary/rigid stance in response to distress. For example, the assignment is helpful in finding spaces beyond the comfort of a mere rhetorical commitment to social justice (‘I commit to working anti-oppressively’), allowing students to ask richer questions about who they want to be in practice, and the values that they hope to embody. Tentative conclusions, rather than a position of certainty, are enabled and encouraged through creative experimentation. Engagement with visuals rather than text is also helpful in opening up spaces for hope, curiosity, and humility regarding possible practices and provisional actions in response to neoliberalism, rather than a sense of hopelessness in the face of immense system constraints.

Valuing lived experience

As a result of the invitation to reflect on experiential knowledges, students appreciate the opportunity to explore the connections between their own experiences and their emerging social work identity. For students with personal experiences of mental health services, this can be a refreshing invitation, contrasting with pressures that they have experienced elsewhere to keep such experiences hidden. In this way, the task seeks to challenge an artificial separation between ‘professionals’ and ‘clients’, which is a driver of othering practices in mental health contexts. However, we do not take a naive position in relation to the complex issue of disclosing lived experience, and we advise students that the sharing of personal experiences should occur on their own terms, and is not compulsory. The visual format of the assignment means that there is flexibility to draw upon personal experiences without providing detail or specificity. In addition, students are encouraged to consider the wide range of experiences that might impact upon their perspectives on distress and difference, including caring roles, activism, volunteering, employment, and media consumption. Indeed, many students have used the assignment as an opportunity to develop powerful analyses of their experiences in the human services sector, reexamining their experiences through themes that they have been exploring within the course (power, rights, justice, feminism, anti-racist praxis, and so on). As noted, the intention is to provide space to engage with multiplicity, rather than any one experiential lens being considered to hold the ‘truth’ about distress.

Inclusion/diversity

Students are overall excited by the task and have also provided extensive feedback about the positive impacts of being invited to produce knowledge in ways that value their multiple skills, beyond an essay format. Although there is institutional rhetoric in higher education about valuing diverse ways of learning, this doesn’t often occur in assessment practices. Students have expressed that in using a creative medium they have been able to see mental health/distress differently and gain new insights into the production of stigma and in terms of their connection to self and connection to others. This has started conversations about practice based on compassion and how creativity is vital to evolving understandings of social work. Through a reduced reliance on words, the task itself puts into practice the relevance of affective knowledges (beyond Eurocentric, techno-rationalist perspectives), in order to contribute toward understandings that transcend psy-expertise.

For some students, it is challenging to use aesthetics as a way of expressing ideas and to see how art could inform ‘professional practice’. At an institutional level, there is a lack of recognition and valuing of art as a rigorous method for critical reflection and analysis and students are disciplined/acculturated into this through prevailing assessment and grading practices. This contradicts what students are taught in social work about the importance of multiple forms of knowledge and studying the social and political context of dominant discourses and practices. For example, in our social work classes we ask students to critically consider the epistemology of ‘social work knowledge’ and how scientific rationalism has legitimated definitions of validity and evidence that exclude other knowledges.

Some students doubt that they are able to complete the task and ask for structure, parameters and terms to direct what they will produce. This creates an opportunity to engage in dialogue with students about how feelings of doubt and uncertainty can be helpful signals in social work, inviting us to think about professional power and how dominant discourses shape our work through the questions we ask and what we see as relevant. Moreover, these feelings can invite us to think about the ways in which we might be reinforcing knowledge, values and practices that silence and exclude the people we work with, perpetuating social injustice. In this way, our emotions/intuitions can support us in practice, helping us to consider whether there is integrity between what we espouse and the process we take.

We acknowledge that every assessment task and form of expression contain constraints and arts-based pedagogies have both strengths and limitations (Leonard et al., 2018). Arts-based pedagogies do not guarantee critical analysis, and a small proportion of students have represented primarily biomedical understandings of mental health within the assignments. While an inherent benefit of creative pedagogies is the potential for multiple interpretations rather than a ‘single truth’, we have found that a written reflection in addition to the visual representation is required in order to support our marking and feedback processes.

Conclusion

In this short article, we have provided our experiences and reflections on the inclusion of a creative assessment task in the curriculum for mental health social work. We are excited by the possibilities for creative pedagogies to support critical thinking, openness to learning, and engagement with multiple forms of knowledge. In addition, the task enables students to move beyond merely talking about social justice issues in mental health, toward an embodied analysis of power and knowledge. Rather than feeling powerless in response to injustices in mental health systems, students often report that the task leads to a heightened confidence and enthusiasm for exploring multiple paradigms in mental health, and engaging with more just and expansive possibilities in their future practice.

Disclosure statement

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