Una indefinición sobre las autonomías territoriales

The combined efforts of an emerging biological psychiatry propelled by the growing use of medication, and the critiques of institutional care, led to a decline in the numbers of people treated in mental hospital beds throughout the second half of the century. Community care therefore became the bedrock of mental health service provision. Evaluation of its operation though, soon came under the same force of critiquing effort as had been directed towards institutional care.

2.6.1 Social/Community Psychiatric Research

Much research focusing on community care operates through the field of social (or community) psychiatry. Its emphasis on social factors makes it a key player in

community research, where social factors are more overtly prevalent then in the days of institutionalisation. According to the Oxford Textbook of Community Psychiatry (2001) research concentrates around several key areas, two of which will be considered here.

Socio-economic status has for some time been reported as a major factor in determining prevalence of mental health, with people from lower socio-economic status reported to be more at risk of developing mental disorders (Neugebauer, Dohrenwend, & Dohrenwend, 1980). This research clearly marks out social and economical practices as active constituents of the operation of mental distress. Claims like this have not just existed in terms of community care, but also right through the history of mental health. These claims are evidenced when looking at diagnosis rates, as people from lower socio-economic status are over represented in diagnostic

populations (Williams, 1999). An oft used argument to attempt to explain this is the social drift hypothesis, which claims that an effect of suffering with mental distress is a gradual decline through socio-economic status, created in part by factors such as losing employment, becoming increasingly isolated (Fox, 1990). Of course, this places the cause for decline on the notion of mental distress, rather than looking at the socio- economic status first, and questioning whether people of lower status tend to be diagnosed more commonly, and thus whether wider cultural factors are at play (e.g. class prejudice). Similar data can be found for gender and race, with women and ethnic minorities more likely to receive diagnoses of mental disorder than white middle class populations (Bayne Smith, 1996; Loring & Powell, 1988).

Recently, the question as to the prevalence of abuse (physical and/or sexual) has been the focus of research (Janssen, Krabbendam, Bak, Hanssen, Vollebergh, de Graaf, & van Os, 2004; Read, 1997). The link between abuse as a causal factor in the

development of mental distress (particularly experiences labelled psychotic) has been highlighted in the critiques of medicalised views of mental health put forward in the pioneering work of Dutch psychiatrists Romme and Escher, and the formation of the HVN (as seen in the previous section). The focus on abuse as a catalysing factor is also reported in a wider set of literature, as summarised by Read, van Os, Morrison and Ross (2005), in which a review of literature revealed prevalence of abuse in the past of people experiencing psychosis to be at minimum 51% and maximum 97%; providing some very strong evidence.

Mechanic (2001) claims that the most important unifying framework in community psychiatry is the ‘stress, coping and social support process’. This refers to the relationship between individual and group, and is used in identifying prevalence of mental disorders along with attempting to guide systems of intervention (Mechanic, 2001). Its basic concept is that the functioning of the relationship between individual and groups depends on the ‘fit’ between individuals’ ability to successfully deal with the challenges presented by social factors. Individuals’ ability is framed in cognitive terms, with people claimed to develop a variety of cognitive-based coping strategies for successfully (or not) managing everyday life in the face of environmental challenges. It is argued that when people struggle to meet the challenges facing them, an increased risk of mental distress exists.

This kind of research involves a different set of concepts. Social practices are framed as influential, but not in a determinant fashion, as ‘resistance’ is incorporated in terms of individuals’ coping strategies. These may not always be successful, but if operating effectively, have the propensity to repel social difficulties. So, mental distress is held as dependent upon the relationship between external and internal factors. Whether

individuals have any potential control over the internal cognitive factors is absent as a question of inquiry.

Research into community care generally revolves around the impact of social factors on instances of mental distress, concentrating on efficacy of service provision, in

addition to continued efforts to illuminate the practices of treatment (e.g. an der Heiden, 2001; Tyrer, 2001). Reading the Oxford Textbook of Community Psychiatry allows a thorough overview of current research into community care. A large portion of the textbook is devoted to evaluating the process of research and community care, rather than analysing aspects of it. Aspects are focused on at a macro level; analysed in terms of their impact on mental health in the community. In this way, they are

conceptualising the role of social practices with regard to the impact on service users. In addition to this, one needs to consider how these kinds of social forces impact on people’s lives in terms of how they are taken on and re-worked. This involves taking into account people’s own agentic actions, in addition to focusing on the one-way direction of social forces upon people.