|Partners for Mental Health - The Contribution of Professionals and Non-professionals to Mental Health (WHO, 1994, 110 p.)|
Rumi K. Price, Ph.D., M.P.E.1
Harsha N. Mookherjee, Ph.D.2
Brent M. Shea, Ph.D.3
Sebastien Reichman, Ph.D4
1. From the Department of Psychiatry, Washington University School of Medicine, U.S.A.
2. From the Department of Sociology and Philosophy, Tennessee Technological University, U.S.A.
3. From the Department of Anthropology and Sociology, Sweet Briar College, U.S.A.
4. From the Clinique des Maladies Mentales, Saint Anne, Paris, France.
The study of mental health and illness encompasses several disciplines including, but not limited to psychiatry, psychology, social work, public health, nursing, anthropology and sociology. While substantive topics are not distinctive across these disciplines, sociology of mental health, as a subfield and outgrowth of sociology, applies the concepts, perspectives, theories and methods of sociology to phenomena related to mental health and illness, including substance use and abuse. The sociology of mental health thus includes a wide range of topics, such as: theories relating to the spread and distribution of psychiatric and substance use disorders among various population groups; social and cultural factors in the causes of mental diseases; behaviors or actions taken by groups to maintain, enhance or restore mental health or cope with mental illness, substance use disorders or resulting disability; mental health professionals and the organization, financing, and delivery of mental health care services; psychiatric and mental health practice as a social and cultural institution, and its relationship to other social and cultural institutions; people's attitudes and beliefs and social representations concerning mental health, illness, substance abuse, disability, and mental health care providers and organizations; as well as cultural values and responses with respect to mental health, illness, substance abuse and disability.1
Most mental health professionals including psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses, and occupational therapists contribute to the areas of mental health and illness, primarily through their psychiatric or mental health practices by treating or counseling patients and, to a lesser extent, by teaching students of these professions. In contrast, sociologists' contributions have traditionally involved research on mental health and dissemination of important findings for public policy. Thus, our present paper is aimed primarily at current and future issues surrounding sociologists' role in mental health from the viewpoint of research needs and public policy.
Sociology of Mental Health and the International Sociological Association. There are two major international organizations in sociology: the International Sociological Association (ISA), and the International Institute of Sociology (US). The US is the oldest Sociological association and has a rich organizational history for established sociologists. Unlike ISA, however, it does not have a section structure representing subfields in sociology. Therefore, our Working Group on Sociology of Mental Health (WG-SMH) within the International Sociological Association represents an international organizational body in sociology clearly identified with the field of mental health and illness.
In this position paper, the Working Group attempts to lay out a foundation for future agenda in Sociological research on mental health and illness, including substance use and abuse. We identify social epidemiological research and research bearing direct impacts on public health and policy, as two major areas needing increased sociological contributions. We also attempt to identify sociology's practical contributions to mental health, beyond its scientific contributions - viewing sociology as an integral part of various professions in the overall field of mental health. Our organizational promotion activities based on our analysis of the current situation of sociology of mental health are described.
2. Historical Background
Sociological exploration into the etiology of mental health and illness can be traced to the beginning of sociology more than a century ago (1). It is usual, however, to consider the sociology of mental health and illness as beginning in the late 1930's, when researchers began documenting the significant relationships between mental illness and social environments using concepts such as social class and residential mobility (2, 3).
Following World War II, the "first-generation" landmark studies of mental health and illness were carried out in the United States (4, 5, 6). Sociocultural and epidemiological studies were also conducted during this period in most regions of the world as well, including Asia (7), Europe (8, 9, 10) and Africa (11). Social psychiatry as a paradigmatic movement to the understanding of mental health and illness flourished during this period (12).
Beginning in the late 1960's and until the early 1980's, sociological research on mental health and illness gradually shifted its focus and approaches. While psychiatry observed the surge of the neo-Kraepelinian paradigm emphasizing the categorical approach to mental illness (13), social scientists shifted their interests from mental illness to mental health problems. Although the effects of macro-sociological variables, in particular, social class, continued to be a focus of debates (14, 15, 16, 17), micro-environmental variables such as social Support and life events began dominating the research on mental health problems (18, 19, 20).
In the United States, researchers with macro-sociological orientations began to apply the deviance approach (21, 22, 23) or the social disorganization (anomie) approach (24) to study mental health and illness, as these approaches became dominant in mainstream sociology during the 1960's and 1970's. These approaches advanced our understanding of some aspects of mental health and illness. Nevertheless, a consequence was a widening gap between sociology and psychiatry; the latter shifted increasingly over the past two decades to biological approaches. Although the gap between sociology and psychiatry was also widening in France during the 1970's, the reasons were quite different: on one hand, psychoanalysis (not biology) became the most influential psychiatric ideology among specialists and the general public, and on the other hand very scarce financial resources were allocated at the national level for sociological studies of mental health and illness. Consequently, the "sociology of psychiatric practices" (25) could never reach a high level of intellectual prestige and autonomy in the medical profession in France.
During this period, medical sociology became a major subfield of sociology in the United States. Notwithstanding a large overlap between medical sociology and sociology of mental health, the former is more distinctive in studying institutional aspects of general medicine as well as psychiatry (26). As impacts of the deinstitutionalization movement grew larger over the two decades, sociological contributions to the understanding of mental health policy (27, 28, 29, 30) added to the growth of medical sociology. A similar trend was observed in France where several sociological and social-psychological studies for the severely mentally ill were carried out utilizing family-based sheltered care facilities (31, 32).
The late 1970's through 1980's marks the flowering of psychiatric epidemiology - a hybrid of sociology (with an application of survey research), epidemiology (in investigation of prevalence, incidence and risk factors of psychiatric disorders), and psychiatry (with standardized assessment of psychiatric cases) (33). The "second-generation" large-scale community mental health surveys were carried out in North America (34, 35, 36), Europe (37), and other parts of the world (38, 39, 40). At the same time, follow-up studies of the first-generation epidemiological studies found many cultural differences as well as overtime changes in the incidence and correlates of mental health and illness (41), reaffirming the importance of sociocultural investigation into the etiology of psychiatric disorders.
A number of sociologists made important contributions to the second-generation studies. Many of them, however, operated outside the traditional discipline of sociology, most frequently in psychiatry and public health. In fact, tension between interdisciplinary researchers engaging in epidemiological research of psychiatric disorders and those in sociology appears to be growing (42, 43). Such a tension is not reducible to the measurement issues of mental illness vis-a-vis mental health problems. Rather, it reflects ostensible differences believed to exist between sociology and psychiatry: sociology purports to explain mental health and illness from a social structural perspective (particularly social control perspective) or from the perspective of symbolic interaction (44, 45); whereas psychiatry tries to understand biological mechanisms manifested in psychiatric disorder.
3. Mental Health Research and the Discipline of Sociology
3.1 Theoretical Approaches
The complexity involved in the etiology of mental health and illness is well expressed in diverse theoretical approaches. Because such a diversity of approaches was in part responsible for diverging disciplines among working sociologists of mental health in developed countries, it is helpful to touch upon these theoretical approaches. We describe three approaches in which sociology has provided essential, landmark contributions to the field of mental health, namely, social learning, societal reaction, and stress approaches. Two other major approaches, psychoanalytic and medical approaches are not discussed here because sociology's impacts on the mental health research from these approaches have been minimal.
3.1.1 Social Learning Approach
This approach was originated in theories of learning and techniques of behavioral conditioning in Skinnerian psychology. From this approach, social behavior was assumed to be learned, therefore, problematic behaviors were thought to be replaceable with appropriate behaviors through behavior modification techniques (46, 47). Behavioral modification has been shown to be effective for some psychiatric problems (48) and substance abuse (49).
Without relying solely on the notion of physiological or psychological conditioning, sociologists have described the learning process from the viewpoints of social control and influence (50, 51). Group norms and peer influences were thought to be the governing principles for learning rather than the principles of reward and punishment. Researchers therefore attempted study the causal mechanism between group membership and influence structure and deviant, bizarre or unacceptable behaviors. This tradition continues in research of mental health and illness, especially in research on substance use and abuse (52).
3.1.2 Societal Reaction Approach
There is a long tradition in sociology of viewing mental illness as a form of deviance: mental illness is thought to be an artifact of social reaction to bizarre behaviors (53, 54, 55). An extreme statement from this perspective reduces mental illness to problems related to sociocultural norms (56). Such a position has been shown to be empirically untenable: cross-cultural studies on behaviors of disturbed individuals suggest that psychotic symptoms such as hallucinations and delusions are universal, despite that contents of symptoms vary by culture (57, 58). Nevertheless, this approach has been successful in pointing out the importance of cultural, situational, and institutional factors in case definition (but not the existence of symptomatology) and treatment selection process. For example, the diagnostic process was found to be influenced by the patient's appearance and demographics (59, 60, 61); and the overrepresentation of minority groups in drug abuse treatment in the United States was attributed to institutional factors rather than reflecting the prevalence distribution of drug abuse in the general population (62).
3.1.3 Stress Approach
A large body of recent literature in medical sociology exists within the stress approach to understanding social psychological mechanisms leading to mental health problems, psychiatric disorders, disability and mental health services utilization (63, 64, 65, 66, 67). In fact, its current dominance is so clear that American medical sociology is often identified with the stress research (68). The notion of stress has been a central concept in sociological research of mental health since the earlier studies in the United States, however, current research distinguishably focuses on understanding the stress process. Thus, although traditional structural variables such as social class and race remain as hypothesized predictors, researchers are increasingly interested in identifying the causal mechanisms leading to the outcomes of interest A series of debates consequently has occurred in recent years over such notions as coping, life events, social support and social networks (69, 70, 71).
Psychiatry shares the stress approach in the categorical concept of post-traumatic stress disorder. Its appearance in psychiatric nosology in the United States (72) was partially political, responding to a large number of reports describing psychiatrically impaired Vietnam veterans (73). During the past several years, however, it has generated psychosocial and epidemiological research on the impact of extreme stress on mental health and psychiatric disorders (74, 75, 76), which is not limited to trauma induced by war experience.
3.2 Diverging Disciplines in Developed Countries
The sociology of mental health has decreasingly been identified with the discipline of sociology in the United States and European countries due to an increased diffusion of its orientation to several disciplines. The interdisciplinary nature of much of current research stems also in part from an increased migration of sociologists engaged in mental health research into other disciplines. A main reason for disciplinary diversion is financial. Since the 1970's, sociology has not been able to sustain the level of financial support it once enjoyed. On the other hand, outside sociology, in particular, in medicine and public health, availability of funding made it possible to allocate academic positions to researchers with social science backgrounds. Some candidates trained in mental health thus began to seek their careers outside sociology (77). In the United States at least, this trend was facilitated by additional facts such as that no existing discipline currently can be identified as the discipline of mental health, and that mental health has never been recognized as mainstream sociology.
Positive consequences of the recent migration into other disciplines include: diffusion of sociological ideas to public health and psychiatry; incorporation of psychiatric and public health ideas into one's own sociological research; and, the opportunity to influence researchers trained in different disciplines, in particular, psychiatrists. On the other hand, the visibility of sociologists in, and sociological contributions to, the field of mental health and illness have been hampered, because important studies and findings have often come out of schools of public health or medicine, despite considerable contributions by sociologists in these institutions. (Obviously there are notable exceptions, e.g., Kessler's large psychosocial study of stress (78)). Further, communication with other sociologists in mainstream sociology is often difficult to maintain, lending the impression that interdisciplinary sociologists are allied with medicine rather than with social science.
3.3 Sociology of Mental Health in Developing Countries
Sociocultural and epidemiological studies carried out by researchers in Pacific-Rim countries have been published in well-circulated journals (79, 80, 81); however, research efforts from Central Asia, Middle-East (except Israel (82)) and Africa, are much less known in the Western literature. Overall, the productivity level in developing countries has lagged far behind developed countries. Concerns regarding developing countries are quite different from those surrounding developed countries, because Western hegemony since World War II over both contemporary mental health research and sociological investigation has led to problematic situations that were specific to developing countries.
Three issues appear important and are highly relevant for our future strategies. The first relates to Euro-American ethonocentrism: contemporary mental health research has tended to ignore cultural aspects of mental health problems as well as indigenous mental health practices (83). Such ignorance by Western researchers is not new, and analogous situations can be found in other fields such as general medicine. However, because developing countries lack a long tradition of sociology, and further sociological approaches developed in the past two decades were themselves reflections of problems in the Western countries, mental health research in developing countries lacks culturally-specific theories, or existing theories that can be uniquely applied to culturally-specific mental health problems and practices.
The second issue is inadequate financial support for indigenous mental health research. Although this can be said about developed countries, the situations in the developing counties are far worse. The developing countries do not really perceive psychiatric disorders and mental health problems as their high priority, given overwhelming domestic problems in other areas (e.g., civil war, famine, poverty). This perception is still prevalent in the countries undergoing rapid social change, where past experiences in western societies (84) would indicate increasing psychiatric and mental health problems. On the other hand, very few funding mechanisms through Western agencies sympathetic to third world research are available, which are aimed at promoting mental health research.
The third issue concerns the manpower problem. There is an insufficient number of native mental health researchers well-trained in the field to produce research which would survive critical review. The number of researchers from developing countries, trained on Western soil, appears to be increasing. Nevertheless, problems are often encountered such as that insufficient time is allowed to absorb new methods and approaches, or that the researchers would become unwilling to go back to their native countries.
Fourth, in developing countries, no professional society has been formed specifically to address the area of mental health from sociological perspectives. In some countries, especially in Asia and Africa, mental health has been in the province of national psychological and psychiatric associations. It is only recently that national sociological and anthropological associations in India, Nigeria, and a few Latin American countries have begun addressing me sociology of mental health. Thus, not only that there is an insufficient number of sociologists in mental heath field, but also organizational mechanisms to promote mental health research are severely lacking in developing countries.
4. Research Agenda for the Future
The Working Group has identified two major areas needing increased sociological contributions to the field of mental health and illness: 1) social epidemiological research of mental health and psychiatric disorders, in particular on research topics that are currently in demand, but which have not received enough attention by working sociologists; and 2) public health and policy related to the urgent issues on which sociologists have not been able to make a large impact.
4.1 Social Epidemiological Research
Research combining sociological and epidemiological approaches has occurred infrequently in the following areas. Although these areas are currently in demand or likely to be in demand in the near future, sociologists' contributions are lagging behind those of researchers in other fields:
Child and adolescent mental health and illness. Past research has demonstrated tremendous impacts of childhood and adolescent behaviors on later adult mental health and illness (85). With the improved reliability and validity of interview assessments for children and adolescents, increasing research and prevention projects on child and adolescent populations are expected in some developed countries (86). Although sociological research has not been absent in this area (87, 88), social scientists' contributions to the understanding of environmental and mental health risk factors influencing current Western problems such as adolescent pregnancy, suicide and homicide, will help provide workable prevention and intervention programs to reduce these unfortunate outcomes.
Population-based survey in developing countries. Existing cross-cultural epidemiological studies in the world regions outside North America owe much to the long-standing initiatives by the World Health Organization (WHO) (41). A decade of the joint venture between the WHO Division of Mental Health, and the United States Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) (89) has now produced standardized psychiatric assessment interviews based on the widely used International Classification of Diseases (ICD) (90) to serve cross-cultural studies of psychiatric disorders and problems (91). Such instruments will allow for comparisons of prevalence and incidence rates among countries not only within the same region, but also across regions. With proper translation and training of interviewers, population-based epidemiological studies in developing countries are feasible now. Such efforts much are needed to understand specific mental health needs of African populations in particular, in which the current climate is focusing only on their physical illnesses.
Abuse and use of psychoactive substances including alcohol, tobacco, and other psychoactive drugs. Although their sociological contributions were often not obvious due to their institutional affiliation, sociologists and other social scientists have actually worked at the leading edge in this area (92, 93, 94, 95, 96). However, a new generation of researchers with social science backgrounds is much needed, given the current magnitude of social problems resulting from substance use and abuse, including its association with HIV infection.
Personality disorders and personality structure. Since the time when sociology turned away from the psychoanalytic approach to instead advocate the deviance approach, personality research in mental health has been conspicuously lacking, and this trend is unlikely to be reversed in the near future. In psychiatry, however, personality disorders are currently in the forefront of inquiry, although nosological schemes of personality disorders still need to be sorted out (97). Sociologists' resistance to including personality factors in the stress process studies is in part ideological. But the accumulated empirical evidence to support the importance of personality is so persuasive that further resistance would alienate sociological research in the field of mental health. Inclusion of personality factors in sociological research does not necessarily endorse heredity or biological factors as the primary antecedents of mental health and illness. To the contrary, behavioral genetics and genetic epidemiology have been sensitive to the importance of environmental factors (98, 99, 100).
4.2 Public Health and Policy
Sociological research can assist in determining the direction of changes on countless public health and policy issues. The Working Group felt, however, that the following three issues are likely to benefit most from increased sociological research. Although we recognize its importance, sociological research on mental health care and utilization was not included, because this is a relatively well-studied area in medical sociology and detailed discussions can be found elsewhere (101).
AIDS/HIV and mental health. Into the third decade since the appearance of AIDS, the global spread of the disease is indeed sobering (102). AIDS being an infectious disease, sociology has much to offer in explicating social processes that affect the course of HIV spread (103, 104). From the mental health point of view, social factors influencing premorbid mental health conditions (which in turn affect the probability, as well as the course of infection) need thorough investigation (105). Such studies will help prevention efforts. Studies on social factors mediating mental health consequences of AIDS/HIV patients will also be valuable as the toll of victims continues to grow. Lastly, research on the impact of AIDS/HIV on community mental health in high prevalence areas would be needed to plan long-term public health strategies. Because AIDS/HIV has often been concentrated in low socioeconomic strata (e.g., migratory labor villages in Central Africa, inner-city ghettos in the United States), individuals in these areas would require community resources to cope with the consequences of AIDS/HIV.
Psychiatric and psychological comorbidity. Recent general-population epidemiological research is primarily responsible for a shift toward the comorbidity paradigm in American psychiatry (106, 107). Currently, however, environmental factors that precipitate or modify the course of comorbidity are not well understood. Studies addressing such issues will be beneficial for identification of individuals at risk for comorbid disorders and problems, and for planning effective intervention and prevention.
The homeless mentally ill. In the developed countries, increasing attention has been given to the homeless in the 1980's. Because low-cost housing is disappearing quickly, the homeless problem is expected to increase even further in the United States. As expected, psychiatric problems have been found to be exceptionally high in this population (108). Because the homeless mentally ill is a very intractable population, careful sociological and epidemiological research (109) on the relationship between homelessness and mental illness can be extremely helpful for intervention efforts.
5. Practical Place of Sociology in the Mental Health Field
Recent communications between the ISA and its constituencies, Research Committees and Working Groups, have focused on the issue of demand for sociology. Serious dialogue has accumulated in assessing the role of sociology in scientific communities as well as in wider public and private sectors. Similar questions can be asked more specifically about sociology of mental health. In an earlier section, we argued that, although disciplinary diversion diminished the visibility of sociology, it also facilitated diffusion of sociological inquiry into a wide variety of disciplines such as psychiatry, public health, and epidemiology. We then identified research agenda that are currently in demand in developing countries or are expected be in demand in a near future in developing countries.
We maintain that research is sociology's most identifiable contribution to the overall field of mental health, and that very few sociologists are direct services providers treating or consulting patients (sociologist's role equivalent to clinician's role as a service provider in relation to patients, would be teaching college and graduate students). There are, however, other practical roles that sociologists have frequently fulfilled in the field of mental health beyond their contributions to research. First is consultation services to mental health professionals, rather than sociologists themselves being investigators. For example, a number of sociologists are providing their expertise services on ongoing instrumentation and psychiatric nosology projects headed by psychiatrists (e.g., WHO's CIDI field trial (91), DSM-IV field trial by American Psychiatric Association (110)). Specific expertise of these sociologists were first acquired through their training in sociology and second by their independent investigation work, which proves to be critical for scientific advancement in related fields. This type of services is similar to biostatisticians' services to the medical community for consultations on statistics, for which clinicians are often ill-trained.
The second function of sociologists is training professionals in other fields of mental health so that they be equipped with knowledge about various environmental factors that affect the patient's prognosis. Faculty with social science background in medical school or school of public health frequently teach medical students, nursing students, psychiatry residents, and are also an integral part of faculty development efforts.
The third role may be called the role of "mental health services analyst". Because training in sociology to study variables relating to stratification is naturally suitable for analysis of health care systems, this has in fact been one of the strongest areas of inquiry in medical sociology (101, 111). Outside the research arena, there still appears to be a high demand for systems analysis. The inquiry might be at the level of demographic trends of specific psychiatric disorders in local areas, which would help administrators of local hospitals to decide on the bed allocation. At a higher level, demands appear increasing for inquiry into inequality of health care provision and utilization, which relate to a national strategy for governmental insurance and taxation.
6. Organizational Promotions by the Working Group on Sociology of Mental Health, ISA
To facilitate collaboration in the areas of research identified above both within and across regions, the Working Group endorses an interdisciplinary approach with a global perspective. Specifically, we propose to:
- Form an advisory board to facilitate the interdisciplinary approach. It is clear that mental health research has become increasingly interdisciplinary. It would become increasingly difficult to maintain unidisciplinary studies within sociology, if they are to have substantial impacts on public health and policy. To increase interdisciplinary communication and collaboration, the Working Group began the process of forming an advisory board consisting of well-established senior scholars from several disciplines including sociology, psychiatry, public health, social work, epidemiology and psychology. The advisory board is also expected to provide critical advice about the future directions of the Working Group.
- Utilize international societies as a vehicle to promote the global perspective. Cross-cultural study is valuable in suggesting the etiologic factors of mental health and illness. Such a global perspective would also fill in the critical gap in research capabilities that exist between developed and developing countries, which have been described earlier. The Working Group is in the position of facilitating the global perspective, by virtue of being an international organization. However, we need effective means of providing information about on-going projects from many parts of the world as well as funding and other opportunities available particularly to researchers from developing countries, and disseminating new research findings. Organizational "interlocking" or networking is one effective means of diffusion of information. For this purpose, we have identified several international and national organizations including the US, the International Epidemiological Association (IEA), the Section on Epidemiology and Community Psychiatry within the World Psychiatric Association (WPA), the newly formed Section of Sociology of Mental Health within the American Sociological Association (ASA), and the Sections of Mental Health, and of Alcohol, Tobacco and Drugs, within the American Public Health Association (APHA). The members of the Working Group's current Executive Board have been in touch with the leaders of these organizations.
Most mental health professionals contribute to the field of mental health and illness primarily through their psychiatric or mental health practices by treating or counselling patients. In contrast, sociologists contribute to the field through their research involvement and, through their research findings, addressing pubic health and policy issues most relevant to current problems. The present paper addressed the current and future issues surrounding the sociologist's role in mental health and illness, focusing on research and its contributions to pubic health and policy. Beyond sociologists' role as mental health researchers, we described additional roles: expertise services, teaching, and health systems analysis are three practical roles that sociologists have been and will continue to fulfill in the overall field of mental health.
This paper presented historical background, contemporary approaches, current diverging trends among sociological researchers in developing countries, and shortcomings in developing countries stemming from a lack of sociological tradition and scarce resources for mental health research. Our analysis suggests that the visibility of sociological contributions to the field of mental health and illness has been hampered in the last decade, in part, because of divergence of sociological research into other disciplines. Absence of strong international organizations has impeded international research collaboration and dissemination of findings, so critical for researchers in developing countries.
The Working Group on Sociology of Mental Health (WG-SMH), International Sociological Association (ISA), proposes a research agenda comprised of four areas of mental health and illness research in which sociological contributions are lagging behind those of other fields: research on child and adolescent mental health and illness; population-based epidemiological research in developing countries; research on substance use and abuse including psychoactive drugs and alcohol; and, studies integrating personality disorders, and personality structure with sociological approaches. To facilitate research most relevant to current public policy issues, more sociological studies are needed to better understand: social variables related to psychiatric and psychological consequences of HIV/AIDS patients, social factors influencing mental health conditions among HIV high-risk populations, and the impact of AIDS/HIV on community mental health; social factors related to psychiatric and psychological comorbidity; and the social epidemiology of the homeless mentally ill. The Working Group attempts to increase international collaboration and coordination among working sociologists in several disciplines to enhance further sociological contributions in these identified areas of research and public policy. The existing national and international organizations to promote this movement are identified and future possibilities are discussed.
1. Adapted and extended from a definition of "Medical Sociology" in U.S. Office of Personnel Management, Classification Standard for Sociology, TS-89, Washington, DC: U.S. Government Printing Office, 1988.
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