7 June 2013

A social paradigm of mental health

Psychiatry should step out of the bubble of mental health and join the disability rights world where the right to live in the community means more than access to psychiatric treatments.

It’s great to see that some leaders of the Global Movement for Mental Health are now saying that mental health professionals alone cannot achieve much mental health impact in resource-scarce settings. The key proponent of this idea is Professor Vikram Patel. He advocates care - yes, including medication – and  psychological and social interventions too. In calling services to respect for autonomy and dignity, he also wants policy makers to focus on reducing social exclusion and discrimination. Situational factors impacting on mental health such as poverty and war also need to be addressed.

Patel takes the view that the models used in the north and west have little chance of addressing the huge “treatment gap” between those with mental health problems, and those with access to appropriate care and treatment. Unlike other leaders of global psychiatry who rely on biomedical approaches only, Vikram Patel borrows from public health and suggests doctors tap into the resources of people, of communities. Linking with NGOs, such as BasicNeeds, which are focused on wellness and livelihoods, he is proving how this can work in places like India.

But social psychologists Cathy Campbell and Rochelle Burgess at my alma mater the London School of Economics have pointed out how the Global Movement for Mental Health defines the word “community” too narrowly. For the Movement, the word means “the patient and their families, and lay health workers linked to primary health care facilities.” This definition focuses on human vulnerability rather than resilience with the everyday challenges of life. They and others suggest that instead of quantitative symptom checklists that currently dominate research and practice, people would be better served by participatory research and interventions focused on understanding how people cope and how their wider communities might best be supported to facilitate their coping.

A focus on communities is gaining ground within psychiatry too, at least mainstream psychiatry in the UK, which I am sure is seen as dangerously radical from some places in the world. Social psychiatrists Stefan Priebe, Tom Burns and Tom Craig have written a strident editorial in May’s edition of British Journal of Psychiatry. There they argue for a “social paradigm” of mental health which “requires research to study what happens between people rather than what is wrong with an individual wholly detached from a social context.” Noting the absence of any useful research advances or treatment modalities within the last 30 years, they observe that, “community care has been established, with services that work in the community, but rarely with the community”.

These social capital models snuggle up close to a human rights-based approach, where community living is no longer merely a favourable policy option. Article 19 of the UN Convention on the Rights of Persons with Disabilities sets out rights to choose where and with whom to live, to access a range of community support services and to access without discrimination regular facilities for the general population. The key to Article 19 are services which prevent segregation or isolation.

Community is a difficult concept to pin down. But whatever meaning we ascribe to it, unleashing its supportive potential so as to give effect to human rights standards is an important task for interdisciplinary scholarship. Psychiatrists should join this discourse and contribute back so that people with other types of disabilities can benefit from their insights.



Catherine Campbell and Rochelle Burgess. “The role of communities in advancing the goals of the Movement for Global Mental Health.” Transcultural Psychiatry 49:3-4 (2012) 379-395

Vikram Patel. “Global Mental Health: From Science to Action.” Harv Rev Psychiatry 20:1 (2012) 6-12

Stefan Priebe, Tom Burns, and Tom Craig. “The future of academic psychiatry may be social.” The British Journal of Psychiatry 202 (2013) 1-2