Table Of ContentMaria Borcsa
Carla Willig Editors
Qualitative
Research
Methods in
Mental Health
Innovative and Collaborative
Approaches
Qualitative Research Methods in Mental Health
·
Maria Borcsa Carla Willig
Editors
Qualitative Research
Methods in Mental Health
Innovative and Collaborative Approaches
Editors
MariaBorcsa CarlaWillig
InstituteofSocialMedicine DepartmentofPsychology
RehabilitationSciencesandHealthcareResearch City,UniversityofLondon
UniversityofAppliedSciencesNordhausen London,UK
Nordhausen,Germany
ISBN978-3-030-65330-9 ISBN978-3-030-65331-6 (eBook)
https://doi.org/10.1007/978-3-030-65331-6
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Foreword
Thisbookisverytimelyandmuchneeded,andinthisforeword,Iwillexplainwhy
Ithinkso.
Mentalhealthhasfinallycomeoutoftheshadows.Thereisanincreasingunder-
standinggloballythatmentalhealthandwell-beingarenotanymoreinthemargins
ofpoliciesandhumandevelopment.Mentalhealth,asanewpriority,appearsnowto
beoftenthefocusofpoliciesrelatingtohealth,socialwelfare,educationandother
areasofsocietallife.Recently,therehavebeenmanyhigh-levelglobal,regional,and
nationaldecisionsaboutthecentralroleofmentalhealthandwell-beinginshaping
the future of societies. It is strange that the world had to wait so long to come to
its conclusion about this importance, and now, we have the opportunity to reflect
on what may have been behind such a long delay. In addition, the time has come
to invest more in the promotion of mental health of individuals and societies, and
to develop effective ways of prevention, support, care and recovery in the field of
mentalhealth.
There seems to be a broad consensus regarding this part of the new discourse
about mental health as an emerging priority. This is, actually, an easier part of the
discourse.However,whenwemovetothenextissue,whichisabouthowtoinvest
and how not to invest in mental health, the global community, including experts,
appearstobefarfromconsensus.Thereisdisagreementabouthowresourcesshould
be used, which interventions are effective, what kind of balance should we have
betweenbiomedical,psychologicalandsocialinterventions,andwhethercoercion
isjustifiedinmentalhealthcare.Thelistofquestionswithoutclearanswers,butto
whichtherecouldbeagreement,isverylong.
I had the unique opportunity during the last 6 years to be in the center of this
fascinatingglobaldiscourse,withahugevarietyofopinions,withpassionateexperts
andentireorganizationsformulatingandpresentingtheirversionsoftruth,withquite
dramaticinteractionofscience,practices,policiesaswellaspowerstruggles.In2014,
IwasappointedbytheUNHumanRightsCouncilasaUNSpecialrapporteuronthe
righttophysicalandmentalhealth.ThismeansthatIbecameamandateholder,and
the rule of the game is that the Special rapporteur should keep informing the UN,
thememberstatesandotherstakeholdersabouthowtherighttophysicalandmental
healthshouldberealized–andhowitshouldnot.Becausementalhealthwasalready
v
vi Foreword
emergingasanewpriority,becauseofthelegacyofunderminingtheimportanceof
mentalhealthduringpreviousdecades,andbecausemyownprofessionalbackground
is in mental health (I am a child and adolescent psychiatrist), I decided to make
mental health a priority of my rapporteurship. Therefore, I started to explore the
globalsituationandtoworkonmyreportstotheUN.
Ihavelearnedalotfrommypreviousworkincludinginsightsproducedfrommy
criticalanalysisofthesituationinthefieldofmentalhealthinCentralandEastern
Europe.Inthisregion,thefieldofmentalhealthhasbeenandremains–fordifferent
historicalreasons–affectedbyalegacyofstigma,discrimination,institutionalization
andsocialexclusion.Inaddition,Ihavebeenobservingformanyyearshowideology
was influencing practices, but also outcomes of research. At that time when I was
studyingmedicineandstartedtoworkasayoungpsychiatristandresearcher,mental
healthwasusedbytheSovietUnionasoneofthe“battlefields”oftheColdWar.It
wasofutmostimportanceforSovietideologytoprovethatmentalhealthproblems
can be prevalent in the west, but not in the Soviet Union which, according to that
ideology,havebeeneradicatedbythepoliticalsystem.Theresearchershadtoprove
thatinthecountrywhichwassupposedtobeonthewaytobuildingcommunism,
social and psychological risk factors in the society do not exist anymore. Hence,
mental disorders or mental health problems could emerge only in individuals who
havebiologicallydeterminedmentaldisorders.Thisishowschizophreniaandother
diagnosticcategoriesstartedtobemisused,whichleadfinallyeventothepolitical
abuseofpsychiatryinthatpartoftheworld.ThiswasoneofthelessonsIlearned–
thatalotofstatisticsandbiasedresearchcanperfectlyhidetherealproblems.
However, since 2014 my mandate was global, so I could not focus on just one
regionanylonger.Ineededtocaptureglobalchallengesandopportunities.
Iwastravelingtomanycountries,meetingrepresentativesofgovernments,mental
health professionals, users and ex-users of mental health services. I was attending
numerous meetings and visiting a large number of mental health facilities. Based
onconsultations, sitevisitsand collected informationI prepared several reports to
theUN.Thiswasmyduty—theSpecialrapporteurpreparesandpresentsthematic
reportstotheUNHumanRightsCouncil(HRC)andtotheGeneralAssembly.
Oneofthesereports—thereportwhichIpresentedtotheUNHRCinJune2017,
sparkedsomanyresponses,andtheseresponseswerecharacterizedbysuchabroad
spectrum of views–ranging from extremely positive to extremely negative–that it
couldbeinterestingforsomeonetoexploretheseresponsesassomethingveryunique
andmeaningful“foodforthought”.
Howitcouldhappenthatonegroupofexperts,wellknownintheworldofmental
healthresearchandmentalhealthpolicy,decidesthatthemainmessagesofthereport
of the UN Special rapporteur are correct and should be taken up by governments,
whiletheothergroupofexperts,whoarealsoprominentresearchersandadvisersfor
politicians,concludethatthisreportshouldbedisqualifiedandthatitsmainmessages
arewrongandmisleading?
Thehugepolarization,whichwasrevealedthroughresponsestothereport,isa
reflection of long-standing tensions with regard to the status quo in global mental
healthandtotheway,theglobalcommunityshouldproceed.
Foreword vii
Whilemanyorganizationsandexpertssupportedthemainmessagesofthereport,
onegroupofexpertsandorganizationsthatdidnotagreewiththosemessages,was
mainlyrepresentingtheprofessionalgroupofpsychiatry.
This was not a surprise. My assessment of the current situation in global
mentalhealthwasveryclearaboutthisstatusquobeingunacceptable.Iquestioned
thecentralstatementofthemovementforglobalmentalhealth,whichwasaboutthe
“heavy burden of mental disorders” and the main goal of investments that need to
beincreased,whichistoaddressthetreatmentgap.Oneofmyconclusionswasthat
themainproblemisnottheburdenofmentaldisorders,buttheburdenofobstacles
for the realization of the right to mental health. Three main obstacles that I have
identified were reflecting the dominance of the neurobiological model during the
lastfourdecadesinmentalhealthcareandpsychiatry.Oneobstaclewastheobvious
overuse of the biomedical model and biomedical interventions (mainly treatment
with psychotropic medications) dominating mental health care practices. Another
obstacle was huge power asymmetries—especially between service providers and
servicesusersinmentalhealthcare,butalsobetweenpsychiatristsandothermental
healthcareworkers.Thethirdobstaclewasbiaseduseofknowledgeandevidencein
mentalhealthcare,resultingininformingeveryonethat,forexample,depressionis
aboutchemicalimbalancesinthebrain.
Is this all about denouncing or demonizing the medical model in the field of
mentalhealth?No,Ithinkthatthemedicalmodelandpsychotropicmedicationsdo
have their role in providing care and support to people with mental health needs.
TheproblemIwasraisingwasaboutoveruseandmisuseofsomeinterventions,and
aboutahumanrights-basedapproachbeingunderminedbythedominantideathat
firstofallmentaldisordersshouldbefixedbydoctors,voluntarilyorbyforce,and
onlythendignityandhumanrightscanbeexercised.
Thedominanceofthebiomedicalmodelandbiomedicalinterventionsisbased,
as we know, on research. Here we approach the main theme of the foreword—
whyqualitativeresearchissomuchneeded.Thereasonisthatonemoreimportant
imbalancewascreatedbytheexcessiverelianceandoveruseofquantitativeresearch.
As it appears now, findings of that research have been strongly influenced by the
pharmaceutical industry, and have failed to keep to its promises. We know, and I
haveelaboratedonthisissueinotherreports(suchasmyreportoncorruptionand
righttohealth),thatlargenumbersoffindingsofresearchthatwereinformingthe
stakeholdershavebeenbiased.Medicationsmayhavetheirroleinthemanagement
of mental health conditions. However, evidence about their effectiveness has been
biased, and for many years, patients, doctors and politicians have been receiving
misleadinginformationaboutwhatcouldbethemosteffectivewaytomanagemental
healthconditions.
Torestorethebalanceinresearchandininformingthegeneralpublic,politicians
andmedicaldoctors,goodqualitativeresearchisverymuchneeded.Itisbecoming
evidentnowadays,thatmentalhealthisstronglyaboutthecontext.Itisaboutrelation-
ships,diversities,powerissues,effectsofdiscrimination,inequalitiesandviolence.
Itisabouttheemotionalandpsychosocialenvironmentinwhichwelive.Thisenvi-
ronmentcanandshouldbehealthy,richinsupportiveandrespectfulrelationships.
viii Foreword
Unfortunately,quiteoftenthisenvironmentcanalsobetoxicandcontaminatedwith
hatred,mistrust,violence,xeno-,homo-andallotherkindsofphobia.Largely,mental
healthdependsonthesecontextualandsocialfactors,whichcanbeinvestigatedwith
socialsciencesandqualitativemethods.Behindthephenomenonthatnowadaysis
called depression–considered one of the most prevalent health conditions-power
imbalances might be more important factors, than so-called chemical imbalances
which are still presented in medical textbooks as targets for the management of
depression.
Sadly,duringrecentdecades,thecontextofthesocietalfabricwaslargelyignored,
andweshouldunderstandthatthiswasbecauseoffocusingexcessivelyonthebrain
and on the dominance of the reductionist idea that neurosciences will eventually
provideacureformentalhealthconditions.Theattempttopresentmentalhealthcare
asaclassicalfieldofmedicine,withadesperatesearchfora“cureofmentaldiseases”
has failed. Behind this failure stood mainly the fact that research on societal and
contextualissueswasunderminedandwasconsiderednotasimportantasresearch
onbrain.
There is still a long way to go for this systemic error to be corrected. Despite
increasingevidencethatessentialchangesinmentalhealthpoliciesandservicesare
needed, the lion’s share of mental health budgets in most countries of the world
continues to be allocated to cover expenses of psychotropic medications, psychi-
atrichospitalsandlong-termcareinstitutions.Theexpertopinionsofpersonswith
lived experience (users and ex-users of mental health services), and non-medical
mentalhealthprofessionalsareoftenignoredorundermined.Accordingtoexisting
“unwrittenrules”shapedbydecadesofthestatusquo,psychiatristsaretheexperts
astheyaremedicaldoctorsandthisiswhytheyknowmoreandbetter.Interestingly,
among psychiatrists there is an increasing variety of views as well. However, as a
consequenceofdecadesofdominanceofthebiomedical-neurobiologicalmodel,the
power in decision making belongs to those professionals who hold the view that
psychiatryisafieldofbiomedicineandthatitshouldcontinuetobeso.
Thisisnotablack-and-whitematter.However,weshouldagreethatthetimehas
come for another paradigmatic shift in globalmental health. This is how the field
of mental health is developing; we know from history that mental health care and
psychiatryhasbeenmarkedbyshiftsofparadigm.Ontheonehand,eachsuchshift
was bringing some improvement to the lives and human rights of people who had
mentalhealthconditionsandmentalhealthneeds.Ontheotherhand,thependulum
wasoftenmovingtotheotherextreme,andaftersometimeacriticalmassofevidence
was in place that something has gone wrong (again), and that change is needed
(again).Therehasbeenacontinuoussearchofoptimalbalancewithinthebio-psycho-
social model, to avoid moving too far either to “mindless brain” or to “brainless
mind”.Sonow,inthe20softhetwenty-firstcentury,wehavequitealotofevidence
toidentifyharmfulimbalancesandasymmetriesintheglobalmentalhealthsceneand
tomovetovitallyimportantchanges.Thesechangesneedtobeguidedbyevidence,
which includes outcomes of social sciences and qualitative research, and by fully
embracingahumanrightsbasedapproachwhichhasbeenunderminedsofarbythe
statusquoinglobalmentalhealth.
Foreword ix
To conclude this foreword, let me share some suggestions which might inspire
researchers to contribute even more than before, with a combination of qualitative
and quantitative research, to the development of effective and human rights-based
mentalhealthcareandsupportservices.
Analysisofpowerissuesandtheheavyrelianceoninvoluntary(forced)measures
inmentalhealthcarecouldshedmorelightonhowtoabandonthislegacyofpater-
nalism,coercionanddisempowermentofusersofmentalhealthservices.Analysisof
issuesrelatedtorelationships,diversities,indivisibilityofhumanrights,therapeutic
allianceandtrustcouldprovidecreativesolutionstohowthementalhealthofsociety
andindividuals,includingthosewithmentalhealthchallenges,couldbeeffectively
promoted.
Whilethetraditionofinvestinginquantitativeresearch,focusingonassessment
of global burden of mental disorders, is still quite strong, in order to establish a
betterbalancemorequalitativeresearchisneededtocriticallyaddressthecategorical
approachofdiagnosingmentalhealthconditionsandtheexcessivefocusontargeting
individuals and their brains with biomedical interventions. Protective factors and
howtoinvestinresilienceshouldbeexplored,sothatwedonotexcessivelyrelyon
highlightingriskfactors.
Giventhatthereisquitealotofevidenceregardingthecrisisofbiologicalpsychi-
atryandtheneurobiologicalparadigm,theimportanceofmodernsocialpsychiatry
is increasing. Here, research is needed to pave the way for effective practices that
could be free from coercion and respectful of the human rights of persons with
mentalhealthneeds,includingpersonswithpsychosocial,intellectualandcognitive
disabilities.
Suicide should be investigated as a form of (self-directed) violence and as a
publichealthissue,andmoreresearchinthisdirectioncouldbehelpfultobalance
reductionistbiomedicalexplanationofdepressionandsuicide.Theimpactofadverse
childhoodexperiencesonphysicalandmentalhealthshouldbecomeacentraltheme
ofmodernhealthresearchallovertheworld.
Withregardtostigma,thereisstillquiteastrongmyththatpersonswithmental
health conditions and psychosocial disabilities are dangerous to “normal society”.
We need more concerted efforts, with research and advocacy, to address this kind
of“commonsenseerror”basedonalegacyofstigmaanddiscrimination.Iwould
suggestthehypothesis,thatitisfirstofallthesocalled“normalsociety”thatmay
be dangerous to groups in vulnerable situations, but also to itself, with all these
prejudices,fearsandmythsthatworkasself-fulfillingpropheciesandarereinforced
byoutdatedmentalhealthsystems.
OneoftheimportantmeetingsIhadwasameetingin2019withleadersofGerman
psychiatry. This meeting took place in Berlin, in Luisenstrasse, famous for many
importanteventsanddiscoveriesinthehistoryofmedicine.Amongmonumentsto
famousresearchers,notthatfarfromeachother,Ihadthepleasuretosymbolically
meetandpaytributetotwopeoplewhocontributedwiththeirdiscoveriesandinsights
totwoequallyimportantsidesofmedicineandhealthcare.TheywereRobertKoch
and Rudolf Virchow. Robert Koch discovered specific causative agents for several
infectious diseases and thus contributed to the successes of biomedicine. Rudolf
x Foreword
Virchow reminded, and continues to remind us, never to forget that medicine is a
social science. It is very important to nurture the fragile balance within these two
significantpartsofscienceandpractice—sothattheglobalcommunityiseffective
andsuccessfulinprotectingphysicalandmentalhealthofeveryone.
August2020
DainiusPu¯ras
FormerUNSpecialRapporteurontherighttohealth(2014–2020)
Professor,ClinicofPsychiatry,VilniusUniversity
Vilnius,Lithuania
