May Day is Social Day

May Day is traditionally a celebration of hope and anticipation of summer. Fertility rites involving maypoles, may queens and ‘Obby ‘Osses (OK, only in Padstow) spring up across the country. Ancient customs such as morris dancing and running into the sea naked (reports that the two are connected are yet to be confirmed…) are revived amidst heady celebrations of the end of winter.

May Day is also International Workers Day (and Labour Day in the UK), an international celebration of the achievements of workers and an opportunity to campaign against injustice and oppression. The annual march in London this year highlighted widespread discontent about the government’s austerity measures, for example.

It is perhaps unsurprising that the Tory-led government is seeking to move the May Day bank holiday to October. Proposed in order to extend the tourist season, this move is widely viewed as an attack on the history and traditions of the labour movement. Along with the surge in right-wing protest votes at the local elections, this is further evidence of the zeitgeist of individualism and denial of our shared humanity.

Against the grain, May Day 2013 was marked by psychiatrists calling for a renewed focus on social perspectives in mental health. Editorials in two of the Royal College of Psychiatrists’ journals published on May Day called for psychiatry to embrace a social paradigm and to support the development of ‘identity communities’ of people with mental health problems.

Leading social psychiatrists Stefan Priebe, Tom Burns and Tom Craig argued in an editorial in the British Journal of Psychiatry that significant investment in genetics and neuroscience has not led to any significant changes in psychiatric practice in the last 30 years. While groups such as the Social Perspectives Network have made this point for many years, it is perhaps significant that a leading international psychiatry journal is now highlighting this.

Priebe, Burns and Craig argue that mental health problems are expressed in social interactions and relationships are at the heart of treatment, care, support and recovery. The social context in which people live is inextricably connected with the cause and continuation of mental distress and a focus on symptom-reduction is hampering recovery. Attention needs to be paid to connecting people with the communities in which they live (which is what we are doing in the Connecting People study).

The dominance of the neurobiological paradigm in psychiatry, and the profession’s connections with the pharmaceutical industry, are unlikely to permit wholesale changes in the practice of psychiatrists. However, it is good to have allies within psychiatry who can work with mental health social workers and other practitioners working in mental health services and third sector agencies to support individuals’ recovery by focusing on their whole lives and not just their symptoms.

In its sister publication The Psychiatrist, James Mandiberg and Richard Warner, argued that mainstreaming is not always the answer. ‘Mainstreaming’ refers to supporting people with severe mental health problems to live, work and socialise in the ‘normal’ community.

The authors argue that communities largely do not want people with severe mental health problems in their midst and that the latter prefer to be with others who have had similar experiences. Given the stigma of mental distress and the discrimination which people who have these experience face, it is not surprising that communities can be unfriendly and unwelcoming places.

Drawing on their experiences in the US, Mandiberg and Warner argue that publicly-funded services for people with mental health problems are not successful at engaging people with communities and visa versa. They propose the creation of ‘identity communities’ for people with mental health problems whereby people with similar experiences support one another. Such communities can stimulate the creation of social enterprises, but they exemplify their arguments with reference to dated models such as clustered housing and the US-led clubhouse movement.

Mandiberg and Warner draw parallels with enclave communities, which are created by immigrants as they adjust to living in a new country. I fear that the ‘identity communities’ which they propose are at risk of creating enclaves for people with mental health problems, increasing stigma and promoting social exclusion. Peer support is of course important, and many people find it beneficial to their recovery processes, but many people also want to move beyond their identity as a user or survivor of mental health services to live a ‘normal’ life in the community.

Both editorials are welcome contributions to the debate about social models in mental health services. However, they are rehearsing arguments which have been aired frequently over the last 30 years and are arguably anachronistic. Recovery communities based on asset models are thriving in the UK, but have community engagement and not segregation at their core (see Kingston RISE for a good example). It is good to have allies within psychiatry who promote a social paradigm, but they need to fully engage with community development models to realise its potential.

Fundamental change is required for mental health services to be able to implement social models. But these editorials do not challenge the one thing which holds this back: the dominance of psychiatry.