A qualitative exploration of the nature of the medical model in self-management of mental illness: navigating paradoxes and forfeits

Abstract

Self-management is widely promoted in policy and practice as a way to manage mental illness but, despite many years of effort, a wide variety of those who promote/use it perceive that it is not living up to expectations. I wanted to explore how self-management for mental illness was understood, more specifically whether the ‘person-centred’ model that is often promoted alongside ‘self-management’ was evident or if the ‘medical model’ prevailed. This may shed light on the way in which self-care is viewed and enacted by both policymakers and practitioners. I devised a three-stage qualitative study asking 1) how policymakers understand self-management for mental illness, 2) how people and healthcare practitioners understand it in relation to bipolar affective disorder, and 3) how a small group of people understand it more generally as it relates to mental illness. After the three stages I concluded that, despite some differences, in policy and healthcare practice self-management is understood medically in a particular way, in terms of what is done, by whom, how, and why. Central to that understanding is a paradoxical epistemology which limits how much a person living with a diagnosis can know about themselves, and privileges how much other people know about them. The epistemic paradox is resolved in practice by what I have termed “epistemic forfeit”, whereby individuals living with a diagnosis share the task of monitoring their health with others on an ongoing basis. This means that self-management of mental illness is a task which must always be shared by healthcare professionals, and sharing is thus a condition of receiving care. The capacity to share this task is however restricted because services are under increasing financial, time, and caseload pressure. I argue that this may contribute to the sense that self-management is not working in practice. The thesis ends with a set of recommendations regarding how the healthcare system might adapt to provide the oversight medically understood self-management requires.