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Recent conferences, Q&A of paper presentations, and even my NHS REC meeting have recently made me question the impact of social research within mental health and the ‘so what?’ factor of non-clinical studies.  We live and work in an evidence-based system whereby the expectation is that results are observable, measurable, quantifiable and replicable.  Hence studies that value the lived experience of participants, and look for meaning rather than outcomes, can struggle to maintain a sense of validity and reliability within mental health research.

However, there is much that value-based research can offer.  As Larsen (2007) points out, evidenced-based studies that examine therapeutic intervention has a propensity to create the “black box” effect.  The research may show whether outcomes have been achieved, but it cannot address exactly how they were met.  Furthermore, these studies cannot say why these outcomes matter and who they matter to.  This omission is fairly significant given the discrepancies between provider and patient expectations.  Gilburt, Rose and Slade (2008:8) argue that ‘[d]ivisions in the views of patients and professionals in terms of what variables and themes are important mean that the resulting studies may be a poor representation of the user perspective’. Furthermore, evidence-based research ignores personal agency and creativity as it requires that support be routinised according to a set of rational mechanisms that are universally applied (Haigh, 2005).  From this perspective, individuals need only respond to a prescribed agenda of recovery rather than find meaning from their own unique experiences (Rose, 1999).  Thus in order to avoid prioritising “what works” over “what matters” (Haigh, 2005), we need studies that emphasise participants’ experiences of mental health and the outcomes that are important to them.

But there is an even greater ‘so what?’ question that value-based researchers within mental health must address.  Even if we can convince our audiences that value-based research is meaningful and needed, what do we actually do with it?  The conclusion section of many journal articles advocating the prioritisation of participant experiences usually end by saying something along the lines of, “the evidence-base should be expanded”, and/or, “what matters to participants should inform clinical practice and guide policy making”.  Whilst I wholeheartedly agree, I also cannot help but notice that they do not offer any suggestions on how to do this.

Given the evidence-based system that relies on outcomes that are deemed to be achievable and measurable, the direct impact of value-based research is not always obvious.  However it is well worth considering the practical implications of how exploring participant perspectives and highlighting lived experiences can have a real-world impact within mental health.

Posted by:
Jenelle Clarke
ESRC PhD Student (Sociology)
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References:
Gilburt, H., Rose, D. and Slade, M. (2008) The Importance of relationships in mental health care: a qualitative study of service users’ experiences of psychiatric hospital admission in the UK. BMC Health Services Research 8(92).  Available online: http://www.biomedcentral.com/1472-6963/8/92.

Haigh, R. (2005) The Trouble with Modernisation: we need better relationships, not policies and procedures. Mental Health Review Journal 10(3): pp.3-7.

Larsen, J.A. (2007) Understanding a Complex Intervention: Person-centred ethnography in early psychosis. Journal of Mental Health 16(3): pp.333-345.

Rose, N. (1999) Governing the Soul: the shaping of the private self. London: Free Association Books.

Turner (2002) identifies that recovery has been described as an idea, a movement, a philosophy, a set of values, a policy mantra and also a doctrine for change.  It splits opinion between those who view it as simplistic and obvious and others who see its revolutionary and transformatory potential.  Although increasingly fashionable within current mental health policy and practice, there are precedents for recovery as far back as the seventeenth and eighteenth centuries.  For example Phillippe Pinel appointed ex-service users in a bid for a humane regime at Biceptre in Paris and William Tuke developed moral therapy and self management approaches at the York retreat (Scull, 1981).  However, the roots of recovery are most firmly established in movements of protest intended to improve conditions in asylums and to give equal rights to citizens with disabilities.  Judy Chamberlin articulates these rights based approach when she appeals for recognition of the skills and abilities of people with mental health problems to make their own decisions, run their own lives and provide support for one another (1990, 1978).  While the normative claims of recovery have been adopted within English policy, its implementation in mainstream services is heavily critiqued by service users; the main point being that recovery has come to mean all things to all people (MIND, 2008).  Indeed there is a risk that its increasingly popular status and dominance as a paradigm within policy discourses will lead to it being co-opted and distorted by policy makers and experts in the field.

With colleagues in the School of Nursing we used Noam Chomsky’s critical methodology, as an exemplar of a left libertarian position, (Edgley, 2000; 2005; 2009) to provide a theoretical analysis and test of the coherence of the recovery model (Edgley et al., 2012).  We also used it as a critical mechanism to judge manifestations of recovery in practice settings.  In Chomsky’s political philosophy we find that hope is both a pre-requisite and a pre-condition for a trusting and supportive environment.  Everyone, whether or not they have mental health problems, need these conditions to be able to access and utilise their creativity in dealing with their current reality.  For Chomsky, hope, our innate creativity and a supportive community are the necessary conditions of freedom.  In Chomsky’s view, if our society nurtured our creative potentials, then our human nature would not confine itself to searching for autonomy and independence but would instead generate interdependent arrangements.  This could have direct implications for the implementation of recovery; it suggests that those experiencing mental ill health need to be the co-creators of policy and practice, rather than its passive recipients and they need to be able to build and use their own theoretical structure such as that offered by Chomsky.  This would protect recovery from being ideologically driven and open to political interpretation and potentially more importantly provide the basis to evaluate and present evidence on its own terms.  As we conclude in the article:

“The recovery paradigm has the essential elements in place, but control over its application – and lives- needs to be reclaimed from the state and experts alike before adoption turns to assimilation or perhaps co-option turns to emasculation.”

Posted by: Dr Nicola Wright Research Fellow: Research Delivery and Support Unit Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Nottinghamshire, Derbyshire and Lincolnshire

References Edgley, A (2000) The Social and Political Thought of Noam Chomsky.  London: Routledge.

Edgley A (2005) Chomsky’s political critique: Essentialism and political theory.  Contemporary Political Theory 4: 129-153.

Edgley A (2009) Manufacturing consistency: Social science, rhetoric and Chomsky’s critique special issue: The Herman-Chomsky propaganda model twenty years on.  Westminster Papers in Communication and Culture 6(2): 23-42.

Edgley A, Stickley T, Wright N and Repper J (2012) The politics of recovery in mental health: A left libertarian policy analysis.  Social Theory and Health 10(2): 121-140.

MIND (2008) Life and Times of a Supermodel.  The Recovery Paradigm for Mental Health.  MindThink Report 3.  London: MIND.

Scull A (1981) Madhouses, Mad-Doctors and Mad-Men: The Social History of Psychiatry in the Victorian Era.  Philadelphia: University of Pennsylvania Press.