Bianca in the neighborhood: moving beyond the ‘reach paradigm’ in public mental health

Abstract

This article offers a critical analysis of how to address social inequalities in mental health. In public mental health, inequalities are commonly construed as a problem of reach, implying that existing mental health expertise often fails to reach low-income groups. We discuss two critiques on the ‘reach-paradigm’ in mental health promotion: the impoverishment of idioms of distress and the tendency to transform complex political issues into clinical ones that are assumed to be backed by evidence. Furthermore, we present the findings of our ethnographic research of an alternative approach to mental health promotion that used media storytelling focused on local knowledge and social context. Our analysis is guided by anthropological research on idioms of distress and sociological literature on health promotion and social inequalities.

Keywords:

• Mental health
• social inequalities

Introduction

Currently epidemiological research states that mental health problems account for one-third of the world’s disability due to ill health among adults (World Health Organization [WHO], 2008a, World Health Organization and Calouste Gulbenkian Foundation, 2014) and that groups with social and economic disadvantage carry the largest part of this burden. In public mental health, socioeconomic inequalities are commonly construed as ‘a challenge of reach.’ The health in all policies approach advocates increasing the reach of mental health interventions and prevention across sectors (Ståhl, Wismar, Ollila, Lahtinen, & Leppo, 2006). The Mental Health-gap (MH-gap) forum devised plans to reach ‘the hard to reach’, especially groups at socioeconomic disadvantage (WHO, 2008b). The mental health literacy movement is a paradigmatic example of the reach approach with its assumption that expert knowledge should increase reach to bridge the mental health gap (Jorm, 2012; Jorm et al., 2008).

Critics with diverse disciplinary backgrounds question the transferability of knowledge and skills that promote mental health (e.g. Patel, 2014; Summerfield, 2008; Watters, 2010). The psychiatrist Patel argues that many efforts at closing the mental health gap ignore the diverging meanings of suffering and mental health, which leads to a ‘credibility gap’ in mental health promotion.

A key problem lies in the gap between the understanding of mental disorder that mental health specialists use, best illustrated by the diagnostic systems and the epidemiological instruments arising from them, and how the rest of the world conceptualizes psychological suffering. (Patel, 2014)

In line with Patel, this article provides a critical perspective on the ‘reach paradigm’ in public mental health and it promotes an innovative approach to mental health promotion and health literacy exemplified by the media project ‘Bianca in the neighborhood’, in short, Bianca (see also Knibbe, De Vries, & Horstman, 2015). In the first section, we sketch the ‘reach paradigm’ as it is articulated in the mental health literacy movement. Next, we describe two important critiques of the reach paradigm, stemming from anthropology and sociology. Against this background, we introduce the Bianca approach in public mental health that prioritizes local knowledge. After having introduced our ethnographic study accompanying the media project, we offer an analysis of the lay-audience discussions generated by Bianca. The analysis takes a focus on the multilayered ‘idioms of distress’, on the ways in which audience interactions facilitated health literacy in a broad sense, and on the ways in which lay-audiences discussed political dimensions of mental health promotion.

The reach paradigm

The health literacy movement is an important example of the effort to increase reach in public health (Kickbusch, Wait, & Maag, 2006; WHO, 1998). The most cited definitions of health literacy of the WHO (cited in Nutbeam, 1998) and the American Medical Association (AMA) emphasize the cognitive skills required to use health information, and ‘function in the health care environment’(American Medical Association [AMA], 1999). However, over the last decade different conceptions of health literacy have been extensively discussed (Freedman et al., 2009; Nutbeam, 2008; Sykes, Wills, Rowlands, & Popple, 2013) and definitions of health literacy have been broadened, to include abilities to make health decisions in everyday life

at home, in the community, at the workplace, the healthcare system, the marketplace, and the political arena. (Kickbusch et al., 2006)

Health literacy researchers have proposed to not only rely on public health experts but to integrate different voices and ideas about knowledge and power in health promotion. Relevant knowledge in this case includes knowledge about social determinants of health, the influence of urban environments, and the skills needed for civic engagement and collective action. (Freedman et al., 2009; Nutbeam, 2008).

Contrary to these developments in public health literacy, research in ‘mental health literacy’ (Furnham & Lousley, 2013; Jorm, 2012; Reavley & Jorm, 2011; Wang et al., 2007) has maintained a narrow approach. Mental health literacy is defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ (Jorm, 2012). In this definition, it is assumed that a correct clinical understanding of mental problems, in terms of DSM diagnostics, such as anxiety or mood disorders, is required for the recognition of mental health problems and for seeking help and prevention. In the current mental health literacy approach, alternative understandings about mental health are considered problematic.

When people do not use mental disorder labels such as depression, they often use more normalizing labels such as stress or life problem. However, these alternative labels are less likely to facilitate professional help seeking. (Jorm, 2012)

Mental health literacy research focuses on

‘correct’ labeling of a disorder; defined as using the currently accepted psychiatric terminology. (Furnham & Lousley, 2013)

Some authors have pointed to the lack of cultural sensitivity of research instruments for measuring health literacy (Kermode, Bowen, Arole, Pathare, & Jorm, 2009; Loo, Wong, & Furnham, 2012) and the controversial character of the DSM (e.g. Frances, 2014), but most mental health literacy projects unreflexively distinguish between ‘correct’ knowledge that conforms to DSM criteria and ‘false beliefs.’

The mental health literacy movement has been embraced in ‘evidence-based policies’ and in this context calls for a broader approach to public mental health (e.g. Government Office for Science, 2008; Wahlbeck, 2015) have met with resistance. The broad frame of ‘well-being’ was recently rejected by the chief medical officer in England, Sally Davies, because it lacks ‘robust evidence’:

… wellbeing is difficult to define, difficult to measure and therefore difficult to integrate in any meaningful way into public mental health. (Davies & Mehta, 2015)

In line with this, the European Parliament also relies on clinical approaches to promote ‘awareness and training programs for everyone in key positions to promote early diagnosis, immediate intervention and proper management of mental health problems’ (European Parliament, 2009). A broader approach to public mental health is often proclaimed but not reflected in these policies.

Critiques against the reach paradigm

Our first critique is based on medical anthropology which has shown that in everyday life people use a great variety of idioms of distress (Groleau & Kirmayer, 2004; Kleinman, 1977; Nichter, 2010).

Idioms of distress are socially and culturally resonant means of experiencing and expressing distress in local worlds. (Nichter, 2010)

While clinical meanings of health and distress can become a part of these idioms, clinical insights cannot simply replace other idioms of distress since they reflect knowledge about relations between the body, emotions, and the social world (Kirmayer, 1989). In a study among Turkish migrants in Denmark, for example, interviewees showed insight into how emotions about social change were experienced as physical sensations of tightness in muscles, chest, and throat, that are connected to sorrow, regret, and longing. (Kirmayer, 1989). Vietnamese immigrants in Canada used a Vietnamese expression describing ‘a social disease of indignation’ to articulate the experiences of injustice, finding that the western concept of depression did not adequately capture their suffering (Groleau & Kirmayer, 2004).

To understand the practical meaning of idioms of distress Nichter (2010) describes the ‘micropolitics’ and dialogical processes of expressing and defining distress and negotiating appropriate responses. The response or lack of response to expressions of suffering is crucial to its experience and social meaning. From this dialogical perspective, the critique on the reach paradigm is directed at impoverishment of idioms in mental health literacy: the disqualification of many non-clinical idioms of distress leads to marginalization or exclusion of relevant experience in these dialogical processes. While this is not a critique of clinical idioms per se, it questions their privileged position in mental health promotion. Bemme and D’Souza’s (2014) warning about simplistic binary oppositions between local and global in mental health also applies to relations between clinical and other idioms of distress. Clinical idioms can add to local idioms and provide new perspectives in these dialogical processes. As Nichter writes he saw how ‘new spaces for the articulation of distress opened up as a result of diagnostic categories de jour (such as ADHD and PTSD) becoming social facts and taking on a social life of their own in popular health sectors’ (Nichter, 2010). Clinical terms can thus add to the multiple idioms of distress involved in dialogical processes, and open space, however, their dominance may also close down routes for expressing and negotiating the meaning of distress, especially when literacy programs tend to disqualify or marginalize other experiences and expressions of mental distress.

A second critique of the reach paradigm is socio-political and refers to the tendency to obscure complex political issues in public mental health and transform them into evidence-based clinical issues. Although the relevance of socioeconomic contexts for health has been well established (Siegrist & Marmot, 2004), many health promotion activities employ individualizing approaches like encouraging the recognition of individual symptoms and stressing individual responsibility for health (Lupton, 2003). This diverts attention away from social and material inequalities (Friedli, 2012). Interventions aiming to promote mental health of deprived populations often rely on cognitive behavioral therapy in which improvements are sought at the individual level without improving social circumstances. As Knifton points out:

Why are we getting people to reframe their social situation without changing people’s social situations? (Knifton, 2015)

Health promotion that is presented as a matter of scientific authority and expertise (Horstman, 2013), obscures the fact that developing and implementing health evidence are political endeavors in which issues of power and responsibility are at play (Lindsay, 2010).

We propose that the disqualification of diverse idioms for mental health problems and the back-staging of political context is counterproductive. The perceived clash between mental health promotion concepts and the social realities of disadvantaged groups threatens the credibility of mental health promotion particularly among groups with low socioeconomic status (LSES) and other cultural groups. As an alternative example, we present a media-based approach in which local knowledge, context, and experience were central.

The Bianca approach: prioritizing local knowledge

These shortcomings of the ‘reach paradigm’ form the background for the mixed media project Bianca (www.biancaindebuurt.nl). Instead of informing the public about mental health risks, this media project aimed to support public learning processes through storytelling about how to deal with challenging socioeconomic situations that affect mental health. This concept of public learning is inspired by the work of the philosopher Van Gunsteren on public governance and citizenship (De Vries & Horstman, 2008; Van Gunsteren, 1998). Van Gunsteren argues that a modern, global, and unpredictable world that lacks an Archimedean point of overview and control, is depending on learning processes in terms of variation and selection. Maintaining relevant variation is important to ensure that different kinds of knowledge that embody different values are available to address unexpected and complex societal problems that are difficult to tame. The high burden of mental disease in LSES neighborhoods can be considered such a complex and tough problem. Within the mental health literacy approach the notion of learning mostly refers to learning via instruction based on one norm, as experts teach people to use the correct, clinical categories to interpret suffering and distress. This route to deal with reach implies a standardization of mental health while, from Van Gunsteren’s perspective, a variety of meanings and practices is essential to enable public learning about mental health.

Bianca is a community-based participatory media project (De Vries, 2014; Wallerstein & Duran, 2008) that aims to promote mental health in low-income neighborhoods in the city of Maastricht (CA 121,000 inhabitants) in the Netherlands. In its first season Bianca produced six short films (12–14 min) broadcasted on local television. The central character, Bianca, is a warmhearted and resolute owner of a gym who provides help or advice in the problems of people visiting her gym and surroundings. In order to invite discussion and further exchange of stories the films have an open-ended character, and show different often opposing characters that are equally open to identification and critique. The films touched upon issues such as financial problems, unemployment, single parenthood, conflicts between children and elderly, parenting dilemmas, adolescents growing up with social media, difficulties of friendship etc. Two storylines are summarized in Table 1. The first series of films was broadcasted on local television in autumn 2013 and spring 2014. Audience rating indicated that most films were watched by 41% of the city population while up to 86% watched occasionally.

Table 1. Storylines of Fabienne and Harie.

Fabienne

Fabienne is a single mother who has a shopping problem. She spends more money than she has, and neglects her son Sven who comes to Bianca for help. Bianca tries to talk with Fabienne about this problem and, drawing on her own experiences with smoking, she suggests that it may be an addiction. Fabienne is ‘not amused’ with Bianca’s interference, starts shouting and walks away

Harie

Harie is an elderly man who is irritated by boys kicking a soccer ball against his garage. He angrily storms outside to tell them to stop. The boys think he is exaggerating and challenge him even more. Seeing this conflict, Bianca cooks up a plan to reconcile the generations in the ceremonial opening of a soccer field. Before she succeeds things escalate with Harie calling police, in his excitement at the moment a policeman arrives, Harie has a heart-attack

Bianca’s storylines were co-produced with filmmakers, people living in low-income neighborhoods, academics, mental health professionals, and local policy-makers. This process involved different types of knowledge and idioms, however, in the course of these collaborations local knowledge of socioeconomic situations that challenge mental health was prioritized. To avoid medicalizing and individualizing problems, the Bianca films pictured local social life and its daily wear and tear and as such the films aimed to give its audience the feeling that they were viewing their own lives (De Vries, 2014). Two of the six films also included idioms commonly used by mental health experts, with notions of ‘addiction’ and ‘depression.’ However, the films did not present clinical cases or purely individual problems. Rather ambiguous socially shared problems affecting mental health were the focus. The films were developed in a cyclical process in which filmmakers collected local stories about distress, wrote initial scripts, showed and discussed tryouts with various groups of lay-citizens and professionals and used their input to rewrite the scripts. The collaborative process allowed the filmmakers to become ‘literate’ in the local idioms of distress, conflicts, and tensions. Since the films pictured neighborhood and city life, they also articulated the current political context in the Netherlands, characterized by a push toward a ‘participation society’, national budget cuts, the reorganization of health care, and high expectations that informal care and volunteer work would increase and have a beneficial effect on neighborhood life.

Methodology

In order to study how audiences interpreted the distressing experiences depicted in the films and perceived opportunities for improvement, qualitative ethnographic research (Henning, Hutter, & Bayley, 2011) was carried out from January 2012 until February 2014 in LSES neighborhoods in Maastricht. In this contribution, we only use the data gathered with lay-participants living or volunteering (helping with finances and mediating conflicts) in low-income neighborhoods. This also includes co-organizers of film meetings with groups: volunteers, youth-, and community-workers. We collected these data via four different routes. First, we organized audio-recorded narrowcastings (group film-viewings) in which social groups in low-income neighborhoods watched and discussed films. A topic list guided the examination of how respondents made sense of the difficulties and stories in the films, in terms of their own lives and in connections with mental health. With lay-participants in low-income neighborhoods three narrowcastings were organized with the try out films (35 participants), and 14 narrowcastings (201 participants) with the finalized films (three of 14 were with volunteer-groups, 18 participants). The number of participants in a narrowcasting ranged from three to 30, however most narrowcastings had between 10 and 20 participants. Participants in the narrowcastings (children, teenagers, parents, elderly, and immigrants) were recruited from low-income neighborhoods in Maastricht in consultation with neighborhood citizens committees. Community workers, youth workers, and volunteers co-organized the narrowcastings and received a short overview of the films, an information letter and a semi structured topic list. Co-organizers also selected the films that according to them were most relevant for their groups. Second, through participant observation, we gained insight into the social issues of the audiences and mapped the social networks surrounding the project such as a neighborhood theater or immigrant groups organizing language lessons. While these data do not play a role in this analysis, they were an important element in the whole study and in establishing relationships with the community. Third, in-depth interviews about one or more Bianca films were held with 13 respondents living in low-income neighborhoods. Interviews had an open structure similar to the narrowcastings. Respondents for interviews were recruited via snowball sampling. Fourth, data about Facebook and Internet use of the Bianca site were collected using social media monitoring (Lejeune, 2013). Interviews and narrowcastings were recorded and transcribed verbatim. Participant observations and conversations were documented in detailed notes. All data were stored and organized within Nvivo 9. We provided written and oral information about the research project to participants and oral consent was acquired. The study was carried out in line with the code of conduct for anthropologists (American Anthropological Association [AAA], 2009).

Analysis followed a cycle of open coding, identifying recurrent themes and thematic coding guided by research questions, literature, and comparative analysis (Henning et al., 2011). The initial open coding was done by the first author and a student-assistant. Interpretation took place over several rounds with the research team. Thematic analysis was guided by the two critiques on the reach paradigm and by Bianca’s alternative approach to health literacy in a broader sense promoted by storytelling. We mapped how audiences negotiated the meaning of suffering and routes to improvement with multiple idioms of distress, how Bianca-conversations promoted health literacy by mapping opportunities for individual and collective actions to improve healthy living conditions, and how audience members related to the political assumptions shown by Bianca. In this analysis we focus on the data collected in interviews and narrowcastings. Data collected in participant observation served to contextualize and interpret the audience conversations sparked by Bianca.

Results

Below, we describe the diverse idioms of distress that were used in narrowcastings and interviews about the Bianca-films, how meanings of stressful experiences were negotiated, how opportunities for improvement were identified, and how audiences allocated responsibility for improvement in mental health. We focus on responses of lay-audiences living in low-income neighborhoods to the films Fabienne and Harie (see Table 1).

Multi-layered idioms of distress

In a commentary on idioms of distress, Mark Nichter discussed the micro-politics of expressing distress. He described the dialogical processes of negotiating meaning within different social settings, and demonstrated that ‘meaning-making’ has impact on the experience of distress and on routes to relief (Nichter, 2010). Kirmayer organized a great variety of idioms of distress by defining three often used categories: somatic, psychological, and social idioms of distress (Kirmayer, 1989). The idioms of distress in audience discussions about the Bianca films can also be organized in these three categories, however, social idioms of distress were most prevalent.

In social idioms, distress is experienced and understood as a disruption of the socio-moral order (Kirmayer, 1989). In response to the films Fabienne and Harie two types of social disruption were often mentioned: loss of social standing and hostilities. Participants characterized a loss of social standing in stories about themselves or people in their proximity by describing how poverty or financial setbacks lead to shame, a decrease in social contacts, attempts to hide or deny problems, like Fabienne, and a tendency to create more problems in efforts to uphold a certain standing.

I really noticed that this woman used to have better times, and for some reason she cannot live up to that image, but she tries nevertheless, and in doing so she is ruining herself and her child. […] and here, we also have people who used to have a good life but now have to take a step back…

Audience members pointed out that feelings of shame due to poverty also affect the lives of children. When children cannot afford clothing with popular brands ‘Such a child may become a pariah in school.’ Shame may also prevent people from seeking help or support. ‘I have lived through a lot in the last years and after finding no help, I finally found help. You have to overcome this shame.’ These socially disruptive experiences were also connected to macro-social processes. Audience members made connections with individualist ‘consumer culture’: ‘it’s always self self self.’ They sketched a culture in which people compete to show their wealth, even if they have nothing. ‘When one has a nice car the other wants to have an even nicer one, if they have the money or not.’ In this context of consumer culture, poverty is felt as a failure. And addiction was often mentioned as very common in poor families.

Other recurring disruptions of the socio-moral order were experienced in antagonistic contacts between members of different generations. In response to Harie, elderly audience members described an erosion of respect and told about harassments by groups of youth hanging around in the neighborhood.

The children that we see … they only lark about, they respect nothing and nobody.

Some elderly people added however that children cannot be blamed, the problem is really that parents in the current 24 hour economy often have no idea how children spend their time. The audiences thus demonstrated disagreement about the meaning of macro-social issues. Youngsters on their part described that they are met with unreasonable anger and fear in daily life. A young boy mentioned that when he is

just waiting and sitting somewhere, people already start shouting at me.

While youngsters express understanding about the fear of older people they also feel stereotyped and ‘treated as scum.’

Psychological idioms of distress can be defined as expressions of distress that involve implicit or explicit ideas about personhood, the self or the mind (Kirmayer, 1989). In audience discussions, psychological idioms mostly served to describe health consequences of social problems, to show another side of a problem or to relocate a problem. To sketch health consequences, audiences used clinical mental health categories such as depression, burnout, addiction, and suicide. For example, ‘these harassments can really affect your health, it can make you depressed.’ Speaking about financial problems a volunteer helping people to get a grip on their financial situation told:

I was talking to a woman, she said, ‘sometimes I step in the car and I am driving on the highway and I think, my children are fine, they will be cared for. What am I doing here?' So yes that is also a complaint you can get like ‘I would rather crash into something, I have had it’

Mental disorder terms also helped to highlight another side of experiences of social disruption. The anger within intergenerational contacts was occasionally viewed as an issue of personal vulnerability ‘… so with this man I thought, well he must be depressed or something and that is why he cannot tolerate anything.’ Moral indignation about children who do not find their parents at home could be softened by remarks about addiction: Fabienne, a character in one of the films, could not really help herself, ‘she is addicted.’ While clinical mental health terms were often used to reframe experiences of social disruption, they were also embellished with other non-clinical characterizations of psychological processes. For example, ‘it is not only addiction, there is also a feeling of shame behind it.’ In response to Fabienne, a woman rephrased the clinical problem in broader terms of human needs for love and attention:

What I see, actually addiction has many faces and this is one of them, shopping, expensive brands and showing of like ‘I’m doing good’ at the cost of your budget and your kids […] that woman feels lonely, she has no partner, she is looking for love and attention …

Finally, psychological idioms also served to relocate a socially shared problem onto individuals or specific groups. For example, all attempts at overcoming hostilities could be futile because ‘there is no way of talking to that one, he is an antisocial type.’ Youngsters used vernacular to locate the problem: ‘that man he was freaking out when I walked past his car with a snowball and he grabbed me by the throat. They are “wous” (crazy).’ Older participants sketched the psychology of youngsters to explain the origin of harassments: ‘… it is all, pure boredom … .’

Somatic idioms are concerned with bodily experiences and expressions of distress (Kirmayer, 1989). Audiences described the physical impact of social tensions and financial worries in terms of headaches, stomach pain and other ailments. Some indicated that mental problems often are expressed as somatic complaints: ‘… if you are not feeling mentally well, that affects your health. People report all kinds of complaints.’ In response to the film Harie, which pictures a heart attack, audiences expressed worries about their heart problems and concerns about the danger of stress and excitement that may be triggered in irritating contacts with neighbors. An elderly couple described how they were plagued by a noisy group of neighbors and worried about a having a heart-attack in response:

Husband:

The moment that you have this thought, ‘I will call the police’ and then you don’t dare to … .then you keep it inside and then you become really ill. …

Wife:

… then I see that he starts getting in a fret, and yes that is bad for his heart of course, so I stay calm and I say, ‘ah just let them be’.

Somatic idioms were often intertwined with psychological idioms to describe the health impacts of financial problems and social tensions.

I had a burn-out. And I know that it harmed my mental and my physical health. You lose everything and you don’t know where you stand actually.

In short, the open-ended films about daily wears and tears generated conversations in which audiences used multiple idioms of distress to come to an understanding of the problem. These multiple idioms included some clinical mental health terms, but they were not the most important framing of distress, as is assumed in mental health literacy. Clinical terms were used to show concern or relocate a shared problem to individuals. However, social idioms were more prominent in audience discussions.

Public health literacy

To understand if Bianca promoted public health literacy in a broad sense, we focused on the responses proposed in audience discussions to the problems affecting mental health. Public health contributions to the health literacy debate have pointed out that it is not only about recognizing clinical or subclinical symptoms and finding the way in a healthcare system (AMA, 1999; Jorm, 2012; WHO, 1998), it also involves understanding the social determinants of health and capacities for collective action toward improving health (Freedman et al., 2009; Nutbeam, 2008). In this sense, the audience discussions about Bianca contributed to health literacy. Negotiating meanings of suffering with diverse idioms of distress enabled audience members to explore a variety of opportunities for individual and collective action in informal and formal networks, social contacts and in the context of professional help.

On the level of individual actions, elders suggested ways to achieve more pleasant contact with youngsters on the street. For example an elderly man said in response to Harie:

What I experienced with certain kids maybe, they were difficult to handle. If you would give them compliments about things they did well, they had no idea how to deal with that. They had never experienced that … . if you give them compliments and if you later address them about things they do wrong, then they will listen to you.

On the level of collective action, audience members discussing Fabienne imagined ways of transforming the social climate to be less consumer-driven and to make room for other values and social contacts by organizing cultural, music or sport events. Some pointed out that such occasions for contact already exist, meeting places where you can get free coffee as well as free sporting opportunities. Concrete actions that help to change social contacts were often mentioned by youth workers in discussions about Harie:

You bring two groups together, which criticize each other a lot … . The effect is, I think, that people become more tolerant with each other … . youngsters cook dinner for elderly. Then elderly start thinking, ‘how is it possible that 10 youngsters are cooking for 100 elderly. The same youngster that we see with a scooter-helmet on his head in front of the church, looking angry at me when I pass’ … .

Improvements were sought for complex clusters of problems discussed in response to Fabienne involving financial problems, shame and sometimes addiction. Here audience members examined opportunities for help by friends and neighbors as well as the need for professional help. Friends or neighbors can suggest looking for professional help. ‘You could raise the subject and see how they react.’ When problems are denied, as is often reported, neighbors feel responsible to keep an eye on the children involved. Sometimes participants reported trying to address a problem in spite of denial by an afflicted person or family:

you have to go really deep to the roots […]I would go to her home and have a good conversation. I will not make her feel ashamed or bad […]

In sum, lay-audiences proposed a variety of responses to the problems brought to the table by Bianca. Different social and psychological idioms were deployed to indicate opportunities for individual and collective action that are part of public health literacy in a broad sense. Mental health literacy in the narrow sense played a small role when audience members used clinical terms such as depression or addiction to identify a need for professional help.

Front staging politics and the limits of health literacy

Conversations about Bianca as the active and caring citizen of ‘participation society’ also showed the limits of health literacy as the route to health promotion. Friedli (2012) points out that public health faces a paradoxical situation in which increasing insight into the health consequences of socioeconomic inequalities is combined with increased optimism about abilities of people and communities to promote their own health in spite of poverty and lack of power. Audience discussions about Bianca underscored this critique. As far as ‘participation society’ is a response to extreme individualism, the political goals of participation society were endorsed in the interviews:

… lots of people these days, especially young people live for themselves, like ‘listen this is my business’ but that is not how it works in society. It is a good thing that people look after each other, and that is what Bianca does.

However, audiences also criticized the ideology of ‘participation society.’ The high political expectations about citizen participation and community action were contrasted with the social reality of low-income neighborhoods. They pointed to problems such as the frequent relocation of people in the social housing system making neighborly help difficult.

I can tell you, you will not succeed. Today you have a neighbor living next to you, and tomorrow they have moved away.

Relations in the neighborhoods have changed. ‘I grew up in this neighborhood […] everyone knew everyone. I think it used to be like that everywhere. But somehow this fell away. … … .’ People often don’t know each other, and those who have a problem keep it behind closed doors. Moreover, volunteers involved in community activities point out that the government is overburdening neighborhoods.

The municipality and politicians think that we have cans lying around and that if you open these cans that volunteers will come out of them.

The transfer of government responsibilities to citizens and communities is also criticized. ‘I say to myself, fine guys, self-sufficiency, but then the government should create conditions for that.’

This criticism shows that promoting health literacy needs to be accompanied with other improvements. In discussions about opportunities for improvement, audience members recounted their lack of power to make public institutions work for their benefit. Film discussions addressed malfunctioning of health institutions, social housing, and police. In some conversations about Fabienne audience members described the difficulty of finding appropriate help for mental health problems. ‘Nine out of ten people do not find the right entrance to help.’ One audience member mentioned that he was still angry about the failure of health practitioners to understand him:

They should stand for what they have been trained to do. And it doesn’t matter if they have a dictionary of 100.000 words, they should just try to listen to the language of a working man.

In conversations about Harie and their own conflicts, audience members described their lack of power in contacts with police and social housing corporations. ‘Police rarely come if you call them,’ and if they come nothing changes. And social housing corporations refuse to take responsibility for the social consequences of placing so-called ‘multi-problem households.’ A woman described how she tried to help a friend who experienced great difficulty with his neighbors:

His neighbors, you would not think it’s possible, that couple is always fighting, throwing things out of the window … , the police comes three times a week […] with the result that he has heart problems. […]. And the doctor just says, yes ‘you have to move’, yes but you have to have the money for that […] he has been everywhere, environmental police, you name it. This morning in the law center I was also there ‘yes we can do nothing about that sir’ […] his whole life is a wreck. The housing corporation does nothing, the police comes ten times and does nothing, […] called the building and housing inspection department, […] nothing happened.

Audience responses indicated that mental health in a broad sense cannot be discussed nor improved without attending to the political and social realities of disadvantaged neighborhoods and the current functioning and constraints of public institutions.

Discussion

In this article, we critically analyzed the approach to social inequalities in mental health as a problem of reach. The mental health literacy movement is paradigmatic for this ‘reach paradigm,’ as it has the ambition to disseminate clinical perspectives to enhance early recognition of symptoms and help-seeking. As such, mental health literacy takes a narrow focus on clinical terms and ‘correct labeling’ in order to smoothen routes to professional healthcare.

Our analysis of audience interactions with the media project Bianca shows how media can invite storytelling and thereby support public health literacy in a broad sense, and in so doing it provides an alternative to the reach-paradigm. Using multiple idioms of distress, audiences developed shared insights into stressful social conditions and they identified a variety of opportunities for individual and collective action to improve the social conditions affecting health. While clinical terms occasionally helped to map a situation and identify a need for professional help, it was the plurality of idioms that created conditions for imagining and describing appropriate actions. Audience responses to the political dimensions of the media project also show the limits of public health-literacy as the route to health promotion as they pointed to their lack of power in the face of public institutions, most notably social housing, police, and complex health care systems.

Our analysis joins the critical perspectives that have been articulated about dominant approaches to mental health on a global scale (Patel, 2014; Summerfield, 2008; Watters, 2010). ‘The treatment gap,’ the assumption that more treatment should be given to disadvantaged groups across the globe (WHO, 2008b), was criticized by Patel. He questioned whose knowledge and capacities should be involved in mental health care and proposes a paradigm shift moving from

the lack of specialist human resources to the elective mobilization of available human resources. (Patel, 2014)

Our argument about the supposed lack of reach within mental health promotion takes the same direction: instead of focusing on the lack of reach in LSES-groups, mental health promotion should focus on better mobilization of the available knowledge and capacities for mental health within LSES groups. This is also the approach taken in community-based participatory forms of health promotion (Wallerstein & Duran, 2008), the tradition within which Bianca was developed. In our study, it became clear that audiences discussing the films were for instance able to redefine the relationships between older citizens and youngsters and to envision new concrete ways to improve relations between the generations in the neighborhood.

This analysis builds on several traditions in social sciences and health promotion that advocate humility of academic and clinical experts, in order to include more diverse types of knowledge and capacity in practices of health promotion. Such a commitment to the inclusion of knowledge from diverse sources however also raises the question of how clinical knowledge can be of value in health promotion. Our analysis of audience discussions shows that clinical idioms of distress such as depression and addiction opened specific routes to improvement: clinical psychological idioms occasionally helped to show the gravity of a problem, to relocate responsibility, to empathize with someone, or to identify a need for professional help. Clinical idioms clearly have a value in finding opportunities for improving mental health in complex social and financial situations, however, they tend to dominate and reframe other experiences and expressions of distress (e.g. Friedli, 2012; Lupton, 2003). This tendency to take dominance over other idioms requires extra effort to create space for other ways of knowing.

We conclude that addressing social inequalities in mental health requires approaches to health promotion that seek to value relevant variation in this hybrid field of knowledge and capacities. To mobilize the right knowledge and capacities, it is important to address power imbalances and create space for public dialogue using a plurality of idioms. Increasing reach of mental health expertise in a political climate that is already dominated by individualizing, and responsibilizing approaches to health, only aggravates the existing imbalance and diverts attention away from the social and institutional resources for mental health. In this context, a plurality of idioms, especially social idioms may restore balance in health literacy promotion, and help to mobilize social resources for health. However, public dialogue, learning, and collective action also need the support of public institutions such as social housing, police, and health care to shape an environment that supports mental health.

Disclosure statement

No potential conflict of interest was reported by the authors.

Acknowledgements

We are grateful for the help of Mieneke Bakker, Mark Timmer, Sjoerd Cratsborn, and Emke Bosgraaf in this research and for the helpful comments of the anonymous reviewers of this article. Permission for the use of screenshots of the films Fabbiene & Harie in Table 1 was granted by Mind Venture International.

Funding

This work was supported by the research foundation Netherlands Organisation for Health Research and Development (ZonMW) [grant number 200210015]. The media project analyzed in this article was produced by Mind Venture International with support of the Maastricht municipality, CZ Zorgverzekeraar (insurance agency) and the Stichting Elizebeth Strouven (local foundation).