Poverty, pathology and pills: moral narratives and the medicalisation of distress

为精神痛苦提供有效的治疗和支持是卫生部和Mind等民间社会组织的一项既定目标。然而，尽管声明需要解决健康不平等问题，但目前的战略，例如《缩小差距：心理健康基本变革优先事项》（卫生部，2014年），将精神痛苦界定为存在于有关个人内部的心理问题。这不仅表明痛苦可以通过医疗“纠正”，而且还掩盖了往往是痛苦根源的因素，例如恶劣的生活条件，失业。与此同时，限制福利支持的政策和大众媒体，如福利街，利用道德叙事，宣传人们对自己的行为和环境负责的观点。本研究旨在探讨这些道德叙事如何影响低收入社区的人们对物质匮乏和社会劣势造成的精神痛苦的感知和应对方式，并研究其对他们福祉的影响。这将通过在西南部的两个低收入社区进行深入研究来实现，该研究旨在了解：一）人们在日常生活中与精神痛苦有关的道德叙事的定义和使用或抵制方式;二）道德叙事对人们寻求医疗支持的决定的影响。道德叙事如何在全科医生咨询中表现出来，并影响治疗决策和患者福祉;以及iv）哪些应对精神痛苦的措施有可能有效地支持弱势群体，并以有利于患者的方式为关于痛苦医疗化的伦理辩论提供信息，并协助寻求支持低收入社区的从业者和政策制定者。这项为期30个月的研究计划包括两个相互关联的阶段：1）来自2个目标低收入地区的96人将参加焦点小组，探讨道德叙事如何在人们的日常生活中被定义和使用/抵制。将按性别和年龄分组，以确定各组之间的任何差异。第1阶段收集的信息将为第2阶段的数据收集和分析提供知情的背景信息。2)对60个视频记录的咨询进行二次分析，将使我们能够深入了解全科医生和低收入患者讨论精神痛苦的背景。深入分析30次咨询将确定GP-患者互动如何影响处方/接受或拒绝/拒绝治疗的决策。通过对研究地点的10名全科医生的采访以及对40名来自低收入社区的参加过全科医生精神痛苦咨询的人的重复采访，将获得进一步的见解。第一次访谈将侧重于个人的痛苦经历和道德叙事在i）他们寻求医疗咨询的决定中的作用，以及ii）他们对规定/接受或拒绝/拒绝的治疗或干预的反应。第二次面谈将使参与者能够在日常压力的更广泛背景下反思他们的精神痛苦经历，例如生活条件差，他们寻求医疗支持的决定以及GP咨询的结果。该研究计划旨在通过为低收入社区制定有效，有意义和非污名化的精神痛苦应对措施的政策和做法提供信息，对用户群体产生强大而独特的影响。这将通过促进对i）人们对责任的道德叙述的使用/抵制（为什么？什么时候？怎么做？在哪？与谁？）; ii）道德叙事和痛苦的医学化之间的关系; iii）处方抗抑郁药的贫困/剥夺引起的痛苦的伦理影响; iv）确定GP患者的互动，使积极的幸福。

The provision of effective treatment and support for mental distress is a stated aim of the Department of Health and civil society organisations e.g. Mind. Yet despite a stated need to tackle health inequalities, current strategies e.g. Closing the Gap: Priorities for Essential Change in Mental Health (DoH 2014), frame mental distress as a psychological problem that lies within the individual concerned. This not only suggests that distress can be 'corrected' through medical treatment, but also masks the factors that often underlie the root causes of suffering e.g. poor living conditions, unemployment. At the same time, policies in place to restrict welfare support, and popular media e.g. Benefits Street, draw on moralising narratives that promote the idea that people are responsible for their own actions and circumstances. This research aims to explore how these moralising narratives impact on the ways that people in low-income communities perceive and respond to mental distress caused by material deprivation and social disadvantage, and to examine the impacts of this on their wellbeing. This will be achieved through in-depth research in two low-income communities in the South West, which seeks to understand: i) the way that moral narratives are defined and used or resisted in people's everyday lives in relation to mental distress; ii) the influence of moral narratives on people's decisions to seek medical support for distress; iii) how moral narratives manifest within GP consultations and influence treatment decisions and patient wellbeing; and iv) which responses to mental distress have the potential to effectively support vulnerable populations, and to inform ethical debates on the medicalisation of distress in a way that benefits patients, and assists practitioners and policy makers seeking to support low-income communities. This 30 month programme of research consists of two linked stages:1) 96 people from 2 targeted low-income areas will participate in focus groups to explore how moral narratives are defined and used/resisted in people's daily lives. Groups will be divided by gender and age to identify any differences across groups. Information collected in Stage 1 will provide informed contextualisation for data collection and analysis in Stage 2. 2) Secondary analysis of 60 video-recorded consultations will enable insight into the contexts in which GPs and low-income patients discuss mental distress. In-depth analysis of 30 consultations will identify how GP-patient interaction influences decision-making to prescribe/accept or withhold/reject treatment. Further insights will be gained through interviews with 10 GPs in the study sites and repeat interviews with 40 people from low-income communities who have attended a GP consultation for mental distress. The first interview will focus on the person's experiences of distress and the role of moral narratives in i) their decision to seek medical consultation, and ii) their responses to the treatment or intervention prescribed/accepted or withheld/rejected. The second interview will enable participants to reflect on their experiences of mental distress within the wider context of daily pressures e.g. poor living conditions, their decision to seek medical support, and the outcome of the GP consultation. The research programme is intended to have strong and distinctive impacts for user groups by informing policy and practice regarding the development of effective, meaningful and non-stigmatising responses to mental distress in low-income communities. This will be achieved by advancing understanding of i) people's use/resistance of moral narratives of responsibility (why? when? how? where? with who?); ii) the relationship between moral narratives and the medicalisation of distress; iii) the ethical implications of prescribing antidepressants for distress induced by poverty/deprivation; iv) identification of GP-patient interactions that enable positive wellbeing.