How does an individual behaviour or social condition acquire the status of an illness or pathology? What are the scientific and ideological bases of the discourses that do not merely allow a given behaviour to be transposed from social to medical, but also make it socially acceptable, even desirable? Are there social practices that refute the medicalization of social issues, proposing instead innovative approaches that point to civic engagement?

Conrad (2005) states that we are currently witnessing a process of medicalization driven in large part by the medical-industrial complex. As a mode of social control, medicalization has become increasingly pervasive, given the broadened range of influential players—no longer just physicians, but also the pharmaceutical industry, insurers, patient groups, the state and others—who promote the acceptability of its underlying ideologies.

What it means is that medical and social are now increasingly intertwined as opposed to merely overlapping. Indeed, like Conrad, we can distinguish two basic processes: that of medicalization as the shifting of social and moral issues into the field of medicine; and that of the concomitant “healthist/healthicization” discourse that transposes issues of public health to the sphere of moral imperatives and lifestyle choices (Lupton, 1995).

If these two fundamental approaches overlap and intermingle, it is largely through mechanisms that, on the one hand, influence medical reasoning and its moral basis, and on the other, feed into social aspirations that, to varying degrees, converge with the quest for “perfect health.”

Still, as Nye (2003) aptly points out: “The irony of this development is that the goal of a perfectly healthy population—bodies that are ‘natural’ and unmedicalized—can only be achieved by the individual.”

A concrete example can be found in Mario Poirier’s article (Mario Poirier. “Santé mentale et itinerance.”Érudit, Vol. 19, No. 2, spring 2007, p. 76–91.)
on the evolution of the concept of homelessness. Poirier emphasizes that the latter is too often confused with mental illness, leading to the immediate disregard of any underlying social factors. In fact, the prevalence of real mental disorders (i.e. as defined by the DSM) would appear relatively low among homeless populations—indeed, between 10% and 30% in the studies cited by the author, when substance dependence issues are excluded.

Furthermore, while psychotic disorders are undeniably more prevalent on the street than in the population at large, their concentration is insufficiently high to render them constituent features of homelessness. Poirier argues that it is external factors—living conditions, poverty, isolation, lack of family support and so on—which exacerbate psychotic disorders and other mental health problems among homeless populations.

This would also go some way toward explaining why the management of these problems among people experiencing homelessness is more radical (e.g. sudden hospitalization, judicialization) than among individuals with a higher socioeconomic status. Still, the question of a causal link between mental health issues and homelessness cannot be overlooked; and while the chicken-and-egg metaphor would seem fitting, the author makes a clear link between mental deterioration and the exceedingly harsh conditions of living on the street. To the medical categories that are a poor fit for the social and material realities of homelessness may be added the inadequacy of the tools for qualifying and quantifying what is a primarily social problem. Escaping the logic of medicalization requires breaking with an objectifying approach that fails to see any relativity in terms of context. Poirier concludes that clinical settings must make a greater effort to adapt to the particularities of homeless clienteles.

Free translation of an excerpt from the original French text. Johanne Collin and Amnon Jacob Suissa, “Les multiples facettes de la médicalisation du social,” Érudit, Vol. 19, No. 2, Spring 2007, p. 25–33.

Throughout its history, L’Alternative en santé mentale—the Québec alternative movement in mental health—has been marked by debate, questioning, affirmation and innovation. The movement emerged in the late 1970s as part of a North American current known as anti-psychiatry that challenges the fundamental claims and practices of mainstream psychiatry.

Essentially disputing the dominant biomedical model, its identity continues to actively evolve in line with its own practices and approaches. Its vision is based on community and taking an adapted, diversified approach to meeting people’s expressed needs.

L’Alternative is above all a philosophy, a worldview, an alternate view of mental health and those who live with mental health problems.

L’Alternative is also an attitude of respect toward service users, their personal history and their realities, based on a positive and non-pathologized concept of mental health.

L’Alternative subscribes to the belief that community participation and solidarity contribute strongly to well-being, and that every community has the potential to foster individual self-actualization.

L’Alternative challenges the biomedical approach to mental health, which sees things from the standpoint of illness first and foremost. It takes a critical stance toward medical knowledge, rehabilitation models and psychiatric treatments.

As part of the autonomous community action movement, L’Alternative questions the social culture that puts so much emphasis on individual performance and productivity.

Ailleurs and Autrement

Two French terms, ailleurs and autrement (generally translated as “somewhere else” and “differently”) constitute the slogan used by the supporters of deinstitutionalization. Overall, the phrase signifies the desire to develop resources outside of psychiatric institutions and practices other than those used in the asylum. We propose community-based sites and spaces that reflect a different way of seeing mental health. This notion of “difference” manifests through the alternate ways of acting and doing that characterize L’Alternative.

Examples of alternative measures:

• Personal growth workshops
• Personal support
• Group support
• Individual counseling
• Individual therapy
• Group therapy
• Medication self-management*
• Day-to-day support (budget, housing, food)
• Lodgings
• Information
• Reintegration program support (guidance, internships, employment)
• Community support for self-actualization
• Various training courses
• Creative workshops (including art therapy)
• 24-hour crisis line
• Crisis intervention
• Promotion/vigilance

Source: RRASMQ

In their paper (Lourdes Rodriguez del Barrio and Marie-Laurence Poirel. “Émergence d’espaces de parole et d’action autour de l’utilisation de psychotropes.” Érudit, Vol. 19 No. 2, spring 2007, p. 111–127.) on the experience of medication self-management (MSM) among people with mental disorders, Lourdes Rodriguez del Barrio and Marie-Laurence Poirel illustrate the potential that lies in empowering patients in the care process. As a space for speech and action, MSM transforms individual complaints into a collective speaking-out around the use of psychotropic drugs. In this context, the biomedical model serves to standardize and reduce how mental health problems are interpreted and managed. Generating a critical collective discourse on the dominant trends in North American psychiatry, MSM offers a space where different actors can speak freely about medical treatments and their role in the broader picture. Using action research to trace the origins and development of MSM, the authors underscore the need to consider multiple forms of knowledge on psychotropic meds, including the experiential knowledge of users and their families as well as non-academic references. In light of the oft-reported impossibility, on the part of people struggling with psychiatric medication, of creating space for negotiation in their relations with prescribing physicians, alternative mental health resources note the lack of openness provided by restrictive social policies and the preponderance of the biopsychiatric paradigm in the health system. Medication self-management, in contrast, underscores the importance of the ongoing reflection on the use of psychotropic drugs in mental health treatment and the need to mobilize public health with regard to these issues. It also highlights two key facts: 1) psychiatric and biomedical knowledge are part of a social construct in which the definitions of a given condition will change based on context and power relations; 2) people suffering from mental health disorders can, in many cases, exercise a certain control over their lives, including self-medication, if they are accompanied and valued for their skills rather than psychiatrized—often permanently—as “bodies to be medicalized.”

Free translation of an excerpt from the original French text. Johanne Collin and Amnon Jacob Suissa, “Les multiples facettes de la médicalisation du social,” Érudit, Vol. 19, No. 2, Spring 2007, p. 25–33.

Link to the RRASMQ (Regroupement des Ressources Alternatives en Santé Mentale du Québec)

What makes one population healthier than another?

Some argue that the more a society invests in health services, the better the overall health of its population. In other words, the greater the access to advanced treatments, the greater the improvement to public health. Indeed, this idea is widespread. For all that, the science is clear: individual health hinges on multiple and varied factors. For an intervention to be effective, the fight against disease, though essential, is never enough.

Indeed, if interventions were limited to treating illness, the battle would be lost before it had even begun, since nothing would prevent health problems from developing in heretofore healthy individuals. Action must therefore be taken before a problem can arise, i.e. by targeting all the determinants that positively or negatively affect the health of a given population or of particular groups within it.

The wide range of health determinants suggests that the task extends far beyond the field of health services proper. Indeed, it relies on the involvement of multiple stakeholders: not just elected officials, administrators, managers, professionals and case workers from different fields, but also the agents of public awareness.

As with physical health, medication and psychiatry alone are insufficient for addressing issues of mental health.

Various aspects of the health of a population can be considered, depending on which perspective is taken.

Overall health offers a snapshot derived from such indicators as general mortality, life expectancy, disability-free life expectancy, and perceptions of physical and mental health.

Physical health is assessed using data on the diseases and injuries that affect all bodily systems (respiratory, digestive, nervous, reproductive, etc.). Population-wide events such as epidemics, climate change or pollution can also affect the overall picture.

Mental and psychosocial health is evaluated using data on the positive (e.g. life satisfaction) and negative (suicidal ideation, mental disorders, etc.) aspects of mental wellness; on social adaptation issues, including the many forms of violence, neglect and abuse; on social integration; and on childhood development.

Free translation of an excerpt from the original French text. La santé et ses déterminants, Mieux comprendre pour mieux agir. Gouvernement du Québec, 2012.

Determinants of health are the broad range of personal, social, economic and environmental factors that determine individual and population health. The main determinants of health include:

1. Income and social status
2. Employment and working conditions
3. Education and literacy
4. Childhood experiences
5. Physical environments
6. Social supports and coping skills
7. Healthy behaviours
8. Access to health services
9. Biology and genetic endowment
10. Gender
11. Culture
12. Race / Racism

Source: Government of Canada, Social determinants of health and health inequalities