Explaining mental health recovery in the context of structural disadvantage: the unrealised potential of critical realism
Despite the acknowledgement that mental health inequalities are shaped by the interaction of macro-level (structural) and micro-level (individual, agentic) powers, dominant paradigms in mental health research have been ill-equipped to integrate those different levels of influence theoretically and empirically. As a result, an explanatory ‘deficit’ persists as to the causal mechanisms underpinning the impact of social inequalities on mental well-being, particularly mental health recovery. To redress this gap, critical realism has been put forward as a useful metatheoretical alternative. This paper begins by offering a succinct critique of extant mental health recovery research. Mental health recovery is problematised in relation to its dynamic embeddedness in contextual, including macro-structural, conditions. The core tenets and principles of critical realism are then invoked to address the identified philosophical and theoretical inadequacies. This paper argues that critical realism offers promise for explaining how inequality-generating mechanisms, such as social exclusion, may impede recovery. The analytico-conceptual potential of critical realism has remained largely untapped by the extant mental health scholarship. Critical realism offers a holistic and inclusive set of conceptual tools to re-examine the structure–agency nexus in order to advance mental health recovery and inequalities research, and an equity-based policy agenda.
KeywordsHealth inequalities Mental health Recovery Critical realism Public health
- Bhaskar, R. 1989. Reclaiming reality. London: Verso.Google Scholar
- Danermark, B., M. Ekström, L. Jakobsen, and J.C. Karlsson. (2002). Explaining society: Critical realism in the social sciences. New York: Routledge.Google Scholar
- Department of Health. 2001. The journey to recovery—The Government’s vision for mental health care. https://webarchive.nationalarchives.gov.uk/20120503145017, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002700. Accessed 15 January, 2019.
- Farkas, M. 2007. The vision of recovery today: What it is and what it means for services. World Psychiatry 6 (2): 68.Google Scholar
- International Social Science Council, the Institute of Development Studies, and UNESCO. 2016. World social science report 2016: Challenging inequalities: Pathways to a just world. https://espas.secure.europarl.europa.eu/orbis/sites/default/files/generated/document/en/245825e.pdf.
- Morrow, M., and L.H. Malcoe (eds.). 2017. Critical inquiries for social justice in mental health. Toronto: University of Toronto Press.Google Scholar
- New Freedom Commission on Mental Health. 2005. Transforming mental health care in America. The Federal Action Agenda: First Steps. https://store.samhsa.gov/product/Transforming-Mental-Health-Care-in-America/sma05-4060. Accessed 15 January, 2019.
- Noiseux, S., D.T. St-Cyr, E. Corin, P.L. St-Hilaire, R. Morissette, C. Leclerc, D. Fleury, L. Vigneault, and F. Gagnier. 2010. The process of recovery of people with mental illness: The perspectives of patients, family members and care providers: Part 1. BMC Health Services Research 10 (1): 161.CrossRefGoogle Scholar
- Parsell, C., E. Eggins, and G. Marston. 2016. Human agency and social work research: A systematic search and synthesis of social work literature. British Journal of Social Work 47 (1): 238–255.Google Scholar
- Rütten, A., and P. Gelius. 2011. The interplay of structure and agency in health promotion: Integrating a concept of structural change and the policy dimension into a multi-level model and applying it to health promotion principles and practice. Social Science and Medicine 73 (7): 953–959.CrossRefGoogle Scholar
- Sayer, A. 1992. Method in social science: A realist approach, 2nd ed. New York: Routledge.Google Scholar
- Scottish Government. 2012. Mental health strategy for Scotland: 2012-2015. https://www2.gov.scot/resource/0039/00398762.pdf. Accessed 15 January, 2019.
- Shinn, M. 2010. Homelessness, poverty, and social exclusion in the United States and Europe. European Journal on Homelessness 4: 19–44.Google Scholar
- Smith, C. 2011. What is a person?: Rethinking humanity, social life, and the moral good from the person up. Chicago: University of Chicago Press.Google Scholar
- UK Office of the Deputy Prime Minister. 2004. Action on mental health—A guide to promoting social inclusion. https://webarchive.nationalarchives.gov.uk/+/www.cabinetoffice.gov.uk/media/cabinetoffice/social_exclusion_task_force/assets/publications_1997_to_2006/action_on_mh.pdf. Accessed 15 January, 2019.
- US Department of Health and Human Services. 2006. From exclusion to belonging: Transforming mental health care in America. http://www.nationaltasc.org/wp-content/uploads/2012/11/Transforming-Mental-Health-Care-in-America-SAMHSA.pdf. Accessed 15 January, 2019.
- Yanos, P.T., B.J. Felton, S. Tsemberis, and V.A. Frye. 2007. Exploring the role of housing type, neighborhood characteristics, and lifestyle factors in the community integration of formerly homeless persons diagnosed with mental illness. Journal of Mental Health 16 (6): 703–717.CrossRefGoogle Scholar