Conflict and antagonism within global psychiatry: A discourse analysis of organisational responses to the UN reports on rights-based approaches in mental health.

Between 2017 and 2020, the UN Special Rapporteur (SR) Dainius Puras published three reports that called for significant changes to organisation, funding and service provision in mental health care in ways that emphasise inclusive, rights-oriented, democratic and sustainable community health services. This article aims to examine formal organisational responses to the UN mental health reports and consider the underlying arguments that either support or delegitimise the SR stance on the need for a paradigmatic shift towards a human rights-based approach to mental health. By combining several different search strategies to identify organisational responses across the web, a total of 13 organisational responses were included in the analysis. Given the political nature of the responses, concepts from discourse theory were used to analyse the responses. The analysis showed how the responses articulated two binary positions and contesting articulations of good mental health care, which formed a backdrop for rejecting the SR reports in defence of psychiatry. The discussion elucidates how the responses tend to resemble previous ways in which critique has been dealt with mainly by 'biological psychiatry', but that the counter-critical nature of the medical and psychiatric organisational responses remains in contrast to the broader reception within the UN community.

Quality-of-life measurement in depression trials: A consumerist relic.

Quality-of-life measurement in depression is advocated as a patient-centred indicator of recovery, but may instead enhance the mimetic authority of randomised controlled trials (RCTs) which have been roundly critiqued in mental health. In this paper we draw on the social life of methods approach to extend the well-developed critique of RCTs into the field of quality-of-life measurement. We accomplish this through consideration and critique of the conceptual and epistemological development of quality-of-life measurement in depression, including the role of psychometrics in its development. Examining conceptual developments from the 1970s onwards, we consider how the scientific literature on quality-of-life in depression aligns with behavioural economics and consumerism but falls short of engaging with genuinely patient-centred approaches to recovery. We argue that quality-of-life measures in depression were developed within a consumerist model of healthcare in which the medical model was a central pillar and 'choice' a rhetorical device only. While quality-of-life instrument development was largely funded by industry, psychometrics provided no coherent solution to the 'affective fallacy' (high correlations between quality-of-life and depressive symptoms). Industry has largely abandoned the measures, while psychotherapy research has increasingly endorsed them. We argue that in their design and implementation, quality-of-life measures for depression remain based on a commercial model of healthcare, are conceptually flawed and do not support concepts of patient-centred healthcare.

What are dually diagnosed patients' problems represented to be in mental health? A WPR analysis of the multistability purpose of digital health records.

No previous studies have investigated how political measures, opinions and views of people with dual diagnoses, organisational requirements and professional values are purposefully communicated, mediated and/or integrated in digital records in mental health care. It remains unclear how health records function as both clinical vehicles for documentation, audit and quality assurance in patient care as well as political vehicles of power to articulate and reproduce idealised relations among actors and their roles in mental health. Informed by Bacchi's 'What's the problem represented to be' (WPR) approach, we consider how problems of dually diagnosed persons with co-occurring mental health conditions and drug use (DDPs) are represented and how the tools required to fix the patients' problems are communicated and legitimised in 10 digital health records consisting of 3830 pages of data. In the discussion, we distinguish their multiple purposes by discussing how their structure is shaped by broader discourses in health care. Then, we consider how the structure of records delineates professionals' autonomy, discretionary action and service provision in ways that limit possibilities for including mental health patients' experiences and exclude service users' voices from care planning.

Part II: Living Life: A Meta-Synthesis Exploring Recovery as Processual Experiences.

Recovery, a prominent concern in mental health care worldwide, has been variously defined, requiring further clarification of the term as processual. Few studies have comprehensively addressed the nature of recovery processes. This study aims to explore the nature and characteristics of experiences of recovery as processual. The method used is a form of qualitative meta-synthesis that integrates the findings from 28 qualitative studies published during the past 15 years by one research group. Three meta-themes were developed: (a) recovery processes as step-wise, cyclical, and continuous, (b) recovery as everyday experiences, and (c) recovery as relational. These themes describe how recovery is intertwined with the way life in general unfolds in terms of human relationships, learning, coping, and ordinary everyday living. This meta-synthesis consolidates an understanding of recovery as fundamental processes of living in terms of being, doing, and accessing. These processes are contextualized in relation to mental health and/or substance abuse problems and highlight the need for support to facilitate the person's access to necessary personal, social, and material resources to live an ordinary life in recovery.

Complex cases - Complex representations of problems.

Many Danish drug users do not only require services related to drug use, but face other obstacles such as mental illnesses and unemployment. The services are constituted by different types of policies, which represent both overlapping and sometimes conflicting ideas of how to frame, intervene and 'fix' problems. Policy research has mainly focused on these fields separately, however, in this article, we scrutinize policies in the fields drug use and treatment, unemployment and mental health separately and we bring together our findings to conduct a cross-sectorial analysis of how and why citizens with a mix of problems related to the three fields are produced into particular 'kinds' of subjects amenable to particular kind of tools, interventions and outcomes. Methodologically, we apply an explorative, descriptive policy analysis strategy of key policy documents. We conduct an analysis of the content of policy documents in which data sources are coded focusing on key concepts and arguments as well as examining how problem representations are embedded. Analytically, we draw on constructivist approaches exploring how problems and citizens in need of help are represented in different types of policy documents as well as how interventions are legitimized and how methods, tools and outcomes of interventions are represented. The article shows how policies altogether problematize drug users with complex problems as both morally obliged to find inner motivation and willpower and as victims of poor circumstances depriving them the benefits of leading a 'normal' life. This should be 'fixed' by treatment and interventions, resulting in that socially marginalized citizens 'get better' and, hence, are being transformed into 'someone else'. Finally, we discuss the potential benefits and limitations of the ways in which the proposed problems, solutions and expected outcomes are represented.

How Social Relationships Influence Substance Use Disorder Recovery: A Collaborative Narrative Study.

Individuals with a substance use disorder (SUD) often have fewer social support network resources than those without SUDs. This qualitative study examined the role of social relationships in achieving and maintaining stable recovery after many years of SUD. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a SUD and each of whom had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to the study planning, preparation, and initial analyses. The relationship that most participants described as helpful for initiating abstinence was recognition by a peer or a caring relationship with a service provider or sibling. These findings suggest that, to reach and maintain abstinence, it is important to maintain positive relationships and to engage self-agency to protect oneself from the influences of negative relationships. Substance use disorder service providers should increase the extent to which they involve the social networks of clients when designing new treatment approaches. Service providers should also focus more on individualizing services to meet their clients on a personal level, without neglecting professionalism or treatment strategies.

'Men just drink more than women. Women have friends to talk to'-Gendered understandings of depression among healthcare professionals and their implications.

Little is known about how gendered understandings of patients can inform professionals' discretionary actions and decisions to include or exclude in clinical practice. Using Connell's poststructuralist perspectives on gender as an analytic framework, this article aims to investigate how professionals' articulations of depression are framed by signs of masculinity and femininity, and how these articulations inform service provision to patients with depression in clinical psychiatry. Building on interview data drawn from an ethnographic study, the article shows how the professionals' articulations reflected a gender binary that framed how the feminized patients were often connected to psychiatric care while masculinized patients were referred to separate alcohol or substance use treatment outside the psychiatric institution. The article discusses the societal and institutional conditionality of gendered understandings in psychiatry. In spite of several limitations, the article elucidates how professionals' understandings might have wide-ranging implications for the accuracy of epidemiological research and policy, and how they reflect a power struggle between patients and professionals about the legitimate right to interpret patients' conditions and efforts to manage their illness-related problems.

Who and What Does Involvement Involve? A Multi-Sited Field Study of Involvement of Relatives in Danish Psychiatry.

This article gives an account of aspects of a multi-sited field study of involvement of relatives in Danish psychiatry. By following metaphors of involvement across three sites of the psychiatric system-a family site, a clinical site and a policy site-the first author (J.O.) investigated how, and on what grounds, involvement of relatives is perceived in Danish psychiatry. Paradoxically, the current understanding of involvement of relatives fails to take into consideration the perspectives of the relatives per se and families that were being studied. By analyzing involvement from a discourse theoretical perspective laid out by Ernesto Laclau and Chantal Mouffe, the aim of this study is to show how the dominant discourse about involvement at the political and clinical sites is constituted by understandings of mentally ill individuals and by political objectives of involvement. The analysis elucidates how a psycho-ideological discourse positions the mentally ill person as weak, incapable, and ineffective. By contrast, the supporting relative is positioned as a strong, capable, and effective co-therapist. Furthermore, the analysis considers how this dominant discourse of involvement is constituted by a broader discourse of neoliberalism and market orientation, which justifies involvement as a subtle institutionalization of social control. The article highlights that the role of the relative as a co-therapist may be contested by the families' discourse, which emphasizes issues concerning the responsibility toward the mental health of the ill individual as well as toward the psychological milieu of the family.