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Models of mental disorder-The social model

The social model is concerned with the influence of social forces as the causes or precipitants of mental disorder. While the psychodynamic model is principally concerned with the individual and their personal relations, the social model focuses on the person in the context of their society as a whole. Evidence that social forces are central to the aetiology of mental disorder can be traced to the work of Emile Durkheim (1897) who demonstrated that social factors, particularly isolation and the loss of social bonds, were predictive of suicide. We may be more familiar with associations between poor living circumstances in deprived geographical areas and the incidence of physical health problems.

However, this relationship holds also for mental disorders, perhaps because the associated deprivation is usually accompanied by unemployment, loss of social role and a subsequent sense of alienation from mainstream society. At the heart of this model is the premise that we are all prone to mental disturbance when unpleasant events strike us without warning. This fact led Holmes and Rahe (1967) to develop the Social Readjustment Rating Scale, which attributes a severity score to 42 life events according to the degree of change or adaptation they produce in people. Perhaps not surprisingly, bereavement, divorce and starting a new job are high on the list. There is an intuitive appeal to the social model since we are all likely to have experienced major upheavals in our lives that may have caused us to feel psychological distress.

Anxiety and low mood, for example, may be experienced in the run up to a series of exams or in response to the frustrations associated typically with moving house. The social model provides also a rationale for the origin of other types of psychological distress in which delusions, hallucinations and an apparent loss of contact with reality occur. For example, it is known that unexpected life events are associated with the onset of schizophrenia. Furthermore, the levels of critical ‘expressed emotion’ experienced by a person with schizophrenia from family members is predictive of the severity of the person’s condition and, in particular, the likelihood of relapse. Proponents of the social model do not have fixed ideas about what constitutes a psychiatric illness. Indeed, the model is concerned that labelling people with a psychiatric illness may create a disorder itself.

All symptoms and behaviour have to be understood in the context of the society from which they emanate. There are no independent, objective criteria for mental disorder according to the social model, only a boundary line between normal and abnormal that has been set by society. Supporters of the social model aim to help people take up an acceptable role in society once more, rather than to correct a chemical imbalance or recondition specific behaviours. This may involve social skills training, some systemic family therapies (Barker 1981) and more general family interventions involving education on the influence of critical ‘expressed emotion’ . Gournay (1995) has reviewed the use of these interventions by mental health nurses. The social model has experienced something of a renaissance in recent years with its basic premise reflected in Standard One of the NSF for Mental Health (DH 1999), which acknowledges that mental health problems can arise from the adverse effects of social exclusion. Subsequent work has been conducted through the Department of Health (2001) and the Sainsbury Centre for Mental Health’s Citizenship and Community Programme to tackle these adverse effects.

The former outlines a process that will enable groups and agencies to contribute to the promotion of public mental health. The latter is focused more specifically on strategies to make social inclusion a reality for people with severe mental health problems. The mental health charity MIND has also reprinted their 1999 inquiry into social exclusion and mental health problems (MIND 1999). Additionally, there have been recent discussion papers on the modernization of the social model in mental health, and critiques of the role of the media in perpetuating a perception of the mentally ill as violent and dangerous.

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