A Psychological Approach to Public Mental Health
The global annual direct and indirect costs of psychiatric disorders has been estimated as exceeding $2.7 trillion. It is a truth evident to most ordinary people, and supported by the testimonies of most service users, that these disorders rarely occur in the absence of a background of stress or social adversity. Epidemiologicalresearch supported by meta-analyses confirms strong associations betweendisorders and specific socioeconomic and geographical conditions such aspoverty and inequality, urban environments, migration or livingsurrounded by people of different ethnicity. Individual-specific riskfactors include childhood traumas such as sexual and physical abuse and otherkinds of maltreatment, separation from a parent at an early age, bullying atschool and adult adversities such as debt, unhappy romanticrelationships and workplace stress. Importantly, these factors appearto confer risk not only for the most common types of illness (anxiety anddepression) but also the more severe forms (psychosis), and some of therelevant social drivers have become more severe over recent history, as people,especially in the developed world, have become more isolated, are migratingmore and are increasingly likely to live in urban environments.
It is unrealistic to expect this mountain of need to be addressed by increasing the availability of conventional mental health resources. As recognised by numerous policymakers, there is the potential to dramatically reduce the prevalence of ill-health (including mental ill-health) in populations by addressing social determinants. However, there is yet no coherent science of public mental health (PMH) to guide intervention, and PMH interventions remain patchy and poorly resourced (in the UK, only 1.6% of dwindling public health budgets are devoted to mental health). In this workshop I will explore several impediments to developing the necessary science base: (i) the difficulty in defining psychiatric disorders; (ii) the difficulties in establishing that social factors are causal, and in excluding genetic confounding; (iii) the complexity of the social environment (in which risk factors such as poverty, poor housing, crime rates covary and are difficult to disaggregate). I will sketch the outlines of a psychologically-informed approach to PMH and describe an agenda for its further development.
Paranoia as a disorder of belonging
Paranoid (persecutory) delusions are the most common symptom of psychosis and, arguably, ubiquitous in the earliest stages of illness. There is now compelling evidence that these delusions exist on a continuum with subclinical paranoia as experienced at times by most ordinary people. A generation of psychological models (e.g. Bentall et al. 2011; Freeman, 2016) have converged on the idea that cognitive biases coupled to low self-esteem make important contributions to these experiences, and have had some succes in guiding the development of psychological interventions. However, these models have some limitations: (i) they do not articulate how delusions are different from other kinds of firmly held beliefs (eg. political ideologies); (ii) they are not rooted within a developmental framework; (iii) they emphasize the role of explicit cognitive processes but we now know that implicit (associative) processes play an important role in human cognition. This update will include new data: (i) a network analysis of paranoia in relation to other kinds of beliefs and attitudes (political beliefs, conspiracy theories); (ii) findings on the role of attachment in paranoia and on the relationship between social identity (the sense of belonging) and paranoid beliefs; (iii) preliminary findings on how theory of mind deficits moderate the pathway from insecure attachment, making the difference between paranoia and ordinary mistrust. The overall picture should be regarded as an evolution of earlier models, in which paranoia is considered to be a product of the failure to satisfy the human need to belong.