The rhetoric/reality gap in social determinants of mental health
| Pages | 182-193 |
| Date | 29 November 2013 |
| Published date | 29 November 2013 |
| DOI | https://doi.org/10.1108/MHRJ-04-2013-0013 |
| Author | Patrick Larsson |
| Subject Matter | Health & social care,Mental health |
The rhetoric/reality gap in social
determinants of mental health
Patrick Larsson
Dr Patrick Larsson is a
Chartered Counselling
Psychologist, based at
Homerton University Hospital
NHS Foundation Trust,
London, UK.
Abstract
Purpose – The purpose of this paper is to establish that social determinants are vital contributing factors to
mental health difficulties and that, similar to physical health, mental health follows a social gradient. Despite
this acknowledgement, there is a rhetoric/reality gap found in social determinants of mental health (SDMH).
It will be argued in this paper that this rhetoric/reality gap is located on a number of levels, including
theoretical, methodological, practical, political and policy based,which are proposed here to be interrelated.
Design/methodology/approach – The approach is a conceptual analysis of the rhetoric/reality gap found
in SDMH using a critical perspective. It draws on a wide variety of theories in order to provide an analysis of
the issues outlined.
Findings – The paper’s central finding is that there is a dissonance between the dominant ontological,
epistemological and methodological, or axiomatic, focus in contemporary mentalhealth theory and practice
and SDMH. This dissonance has led to a form of “analysis paralysis”on all levels, and the initiatives required
to tackle SDMH have been marginalised in favour of a narrow interpretation of evidence-based research and
its accompanying ideology centring on the individual, which has established itself as a primary position on
what constitutes valid knowledge to the detriment of other views.
Originality/value – The paper offers a critical perspective on an area of SDMH which is often alluded to but
never explicitly explored, and questions the underlying assumptions inherent to mental health theory and
practice. The paper’s value is that it draws attention to this particular dilemma on a wider scale, including on
a political and policy-based level, which is often neglected in mental health theory, and it makes some
recommendations on how to move forward.
Keywords Policy,Politics, Mental health axioms, Rhetoric/reality gap, Social determinants of mental health
Paper type Conceptual paper
Introduction
Social determinants of health (SDH) have been gaining more prominence in the literature,
and although there are still challenges with implementing SDH-orientated policies, it has
nevertheless become a significant part of policy rhetoric (e.g. Commission on the Social
Determinants of Health, 2008; Blas et al., 2011). Social determinants of mental health (SDMH)
are, to an extent, similarly being acknowledged in policy rhetoric, and has also been gathering a
convincing evidence base (e.g. The World Health Report, 2001; Patel et al., 2010; Liang et al.,
2012; Carson et al., 2010; Myer et al., 2008). However, SDMH are often used in conjunction
with contested concepts such as “wellbeing” and does not regularly feature as an area of
intervention in mainstream mental health; also, the translation from policy rhetoric to reality is
currently lacking (see Raphael, 2011, for a similar discussion related to SDH). It would be
erroneous to say that mental health theory is completely devoid of any reference to SDMH,
instead what will be argued here is that SDMH as a framework or area of practice has not been
translated into a coherent perspective within contemporary mental health theory and practice,
and remains a spectre-like presence. As will be discussed in more detail below, this rhetoric/
reality gap might not only exist due to the formidable tasks faced when implementing policy
related to SDMH and subsequent translation into practice, which potentially leads to a form of
The views expressed in the paper
are those of the author alone and
not the employer.
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MENTAL HEALTH REVIEW JOURNAL
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VOL. 18 NO. 4 2013, pp. 182-193, CEmerald Group Publishing Limited, ISSN 1361-9322 DOI 10.1108/MHRJ-04-2013-0013
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