Poverty, pathology and pills: moral narratives and the medicalisation of distress

Lead Research Organisation: University of Exeter
Department Name: University of Exeter Medical School


The provision of effective treatment and support for mental distress is a stated aim of the Department of Health and civil society organisations e.g. Mind. Yet despite a stated need to tackle health inequalities, current strategies e.g. Closing the Gap: Priorities for Essential Change in Mental Health (DoH 2014), frame mental distress as a psychological problem that lies within the individual concerned. This not only suggests that distress can be 'corrected' through medical treatment, but also masks the factors that often underlie the root causes of suffering e.g. poor living conditions, unemployment. At the same time, policies in place to restrict welfare support, and popular media e.g. Benefits Street, draw on moralising narratives that promote the idea that people are responsible for their own actions and circumstances. This research aims to explore how these moralising narratives impact on the ways that people in low-income communities perceive and respond to mental distress caused by material deprivation and social disadvantage, and to examine the impacts of this on their wellbeing. This will be achieved through in-depth research in two low-income communities in the South West, which seeks to understand: i) the way that moral narratives are defined and used or resisted in people's everyday lives in relation to mental distress; ii) the influence of moral narratives on people's decisions to seek medical support for distress; iii) how moral narratives manifest within GP consultations and influence treatment decisions and patient wellbeing; and iv) which responses to mental distress have the potential to effectively support vulnerable populations, and to inform ethical debates on the medicalisation of distress in a way that benefits patients, and assists practitioners and policy makers seeking to support low-income communities.

This 30 month programme of research consists of two linked stages:
1) 96 people from 2 targeted low-income areas will participate in focus groups to explore how moral narratives are defined and used/resisted in people's daily lives. Groups will be divided by gender and age to identify any differences across groups. Information collected in Stage 1 will provide informed contextualisation for data collection and analysis in Stage 2.

2) Secondary analysis of 60 video-recorded consultations will enable insight into the contexts in which GPs and low-income patients discuss mental distress. In-depth analysis of 30 consultations will identify how GP-patient interaction influences decision-making to prescribe/accept or withhold/reject treatment. Further insights will be gained through interviews with 10 GPs in the study sites and repeat interviews with 40 people from low-income communities who have attended a GP consultation for mental distress. The first interview will focus on the person's experiences of distress and the role of moral narratives in i) their decision to seek medical consultation, and ii) their responses to the treatment or intervention prescribed/accepted or withheld/rejected. The second interview will enable participants to reflect on their experiences of mental distress within the wider context of daily pressures e.g. poor living conditions, their decision to seek medical support, and the outcome of the GP consultation.

The research programme is intended to have strong and distinctive impacts for user groups by informing policy and practice regarding the development of effective, meaningful and non-stigmatising responses to mental distress in low-income communities. This will be achieved by advancing understanding of i) people's use/resistance of moral narratives of responsibility (why? when? how? where? with who?); ii) the relationship between moral narratives and the medicalisation of distress; iii) the ethical implications of prescribing antidepressants for distress induced by poverty/deprivation; iv) identification of GP-patient interactions that enable positive wellbeing.

Planned Impact

The project is designed to include key stakeholder's perspectives from the outset and to maximize opportunities for co-production of impact and knowledge exchange through engagement with low-income communities, healthcare professionals, policy makers and civil society organisations (see also Pathways to Impact):
Low-income communities: incorporating patient's perspectives to improve healthcare provision is a core priority of the UK government. Involvement of low-income residents on the project Advisory Board will ensure engagement and impact with low-income communities from the outset. An Introductory workshop in the study sites will enable local communities to negotiate ways of working and participating in the research that will increase the applicability and utility of the study. A Knowledge Co-Production workshop in each site once data is collected will enable communities to discuss findings and i) agree methods of dissemination to other low-income communities e.g. via national C2 network, ii) agree key findings and priorities to inform guidelines on good practice for health practitioners, iii) guide the focus and aims of, and share experiences and ideas at, a high-impact two-day Research-Policy Briefing Seminar in London alongside presentations by experts in the fields of social inequalities, mental health, and community wellbeing e.g. What Works Centre for Wellbeing, Joseph Rowntree Foundation, McPin Foundation.
Health professionals: identification of GP practice (relating to mental distress) that enhances patient wellbeing will be developed into guidelines on good practice for health professionals working in low-income communities. Health professionals will draw on their experiences to refine the guidelines at a Regional Practitioner workshop, and agree a dissemination strategy that maximizes their utility for the health sector. Participation in the workshop by local authorities charged with health provision e.g. Teignbridge DC & Plymouth CC, will ensure findings feed in to local health plans e.g. Devon Joint Health and Wellbeing Strategy. Networks developed during the project will lead to oral presentations at practitioner-focused events and regional clinical commissioning groups. Impact will be evidenced through changes to working practice amongst GPs that enhance wellbeing in low-income communities.
Civil society groups: valuable relationships will be built through networks of the project Advisory Board (AB) whose members represent key user groups and stakeholders (see Pathways to Impact for confirmed membership). AB members will provide ongoing feedback on the research to their organisations/communities, and develop networking opportunities with other potential user groups e.g. Mental Health Foundation, Young Foundation, Turning Point. User groups will be encouraged to contribute discussion and case studies to the project website, and will promote the research and its findings on their websites. Involvement in the Research-Policy Briefing Seminar will enable academic and user group networking and collaboration, and identify how research findings can be practically and effectively implemented to support low-income communities.
Policy: Joining up understandings of mental distress with the broader social and structural context in which they are experienced will provide key policy makers (with whom links will be fostered via the AB) e.g. Dept. of Health, Dept. for Communities & Local Government, Dept. for Work & Pensions, as well as the cross sector Mental Health Taskforce and public bodies e.g. Social Mobility & Child Poverty Commission, Fairness Commissions, with an evidence base to inform implementation of key strategies e.g. No Health Without Mental Health Implementation Framework (Centre for Mental Health et al. 2012). Internationally, findings will inform the WHO Europe Health 2020 policy to reduce health inequalities via Thomas's (PI) work with WHO on cultural determinants of health (see Pathways to Impact).


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