Paul Bomke, CEO of Pfalzklinikum outlines why mental health requires a social change…
In the field of mental health, the paradigmatic distinction between the treatment of diseases on the one hand and health promotion on the other becomes particularly evident. Although the necessity to prevent mental diseases is obvious because the cost for mental health care has risen enormously in Germany in the last few years, the major part of the resources is invested reactively, i.e. when an increased risk disposition or a disease has been diagnosed. Therefore, in terms of the pathogenetic approach it is rather a treatment of diseases than the promotion of health. Strictly speaking, even the term ‘prevention‘, aiming at the reduction of health risks and damages and, thus, looking primarily at avoiding the occurrence or spreading of diseases, is associated rather with disease or potentially disease-causing factors. Health promotion, however, has another focus: From a salutogenetic perspective, it looks at protective factors and resources and aims at strengthening the individual skills for coping with life and at building health-promoting environmental conditions1. A decisive point here is resilience. That is the ability to cope well with changes and the ups and downs of life and to develop oneself under the most adverse conditions2. Sufficient resilience enables the individual to maintain a balance between the subjective perception of stress and one’s own coping resources. Such an approach has a special potential to sustainably improve the population’s mental health because in the development process of mental disorders it starts at the earliest possible time. So it should be possible to reduce not only the incidence rates and the individuals’ disease burden but also excessive treatment and follow-up cost as well as problems due to gaps in medical care. But addressing resilience only by emphasising the individual’s responsibility for preserving mental health carries the risk that relevant socio-contextual factors of mental health promotion are not sufficiently taken into account. This corresponds to wide experiences of health professionals concerned and involved, who clearly state that the current conceptions of mental health and resilience have to be extended and amended. Therefore, it is important to take this systemic and socio-ecological perspective into consideration whenever efforts of mental health promotion are developed3.
From disease communication to health communication
At its core, the promotion of health is a communicative challenge – at the individual level, at the level of the social environment, as well as at the political level and at the level of the society as a whole. On every level it is necessary to initiate a ‘salutogenetic change of perspective‘and to first raise awareness for the value of and the need for resilience. Analogous to the way the health system is focusing on the treatment of diseases rather than on health promotion, communication efforts and public discourses are concentrating on aspects of diseases instead of health: ‘Disease communication‘ – which in the pathogenetic sense focuses on illness and risk factors – is dominating, while a salutogenetic perspective and, thus, mental health and conditions promoting mental health are hardly made a subject of discussion. Accordingly, mainly mental stress and its consequences are recognised as important social topics. These ‘disease-accentuating discourses’ are supposed to be a major cause of the lack of public awareness, understanding of and support for measures to strengthen resilience and it calls for a change of thinking and acting in all social areas. These changes of perspective can only be initiated by communication. Consequently, any effort of mental health promotion requires a ‘resilience-oriented communication strategy’, i.e. to emphasise the importance of mental stability, the requirements and possibilities to strengthen mental health. This should stimulate public awareness and initiate changes in social discourses which can lead to political and programmatic innovations and, finally, make change happen4.
Cognitive schemata and cultural models as starting points
Communicators face the challenge that frequently they do not even reach people with their messages or that messages are understood in a different way than intended. This often results from a large discrepancy between the health and communication experts’ demand for high quality standards of health information on the one hand, and the existing knowledge, problem awareness as well as the willingness and ability of information processing of lay people on the other hand. This particularly holds true for vulnerable and, thus, especially important, target groups. Therefore, the analysis of the factors influencing whether and how information reaches people is fundamental. It depends on the individual’s available cognitive scheme. Schemata are structured and quite stable patterns of knowledge, attitudes, and experiences regarding issues, events, situations, and objects which form a network of associations5. This association network has an impact on how people select, process and respond to information. A cognitive scheme that is culturally shaped and shared in a social group, is referred to as a cultural model.6 Looking at the topic of resilience it is to be assumed that to date, for mental health no differentiated or only a rather biased cognitive scheme or cultural model exists; the awareness for resilience, for the importance of resilience-sensitive attitudes and for the need of promoting resilience has not been considered really relevant in the broad public.
Changing the individual and the public agenda by framing
Adequate communications strategies are capable to influence cognitive schemata or cultural models, impart knowledge and encourage an individual’s self-reference and, thus, open up new roads for our thinking. By using so-called strategic framing7, certain aspects of reality are selected, emphasised and evaluated, while other elements are neglected. Aiming to modify attitudes and cognitive associations referring to resilience requires to emphasise health-related aspects and protective factors and to put this facet of the topic on the public and individual agenda by means of communication and public relations. A comprehensive framing strategy considers the existing perceptions and values of individuals and groups, as well as, the socio-cultural contexts by considering people’s every-day reality and living environment when developing the message. Promising means are illustrative and narrative ways of communication breaking down complex scientific information to simple and low-threshold messages customised for each target group. For instance, metaphors can concretise abstract concepts in such a way that they are easy to understand and activate emotions. As a result, it is possible to reorganise information, fill in gaps of understanding, and, therefore, reframe existing frames and cultural models8. This framing process should take place on all levels of communication in order to change the social debate and initiate a change in the system towards the promotion of resilience.
Bomke, P. & Kendall-Taylor, N. (2014). Framing change. Pan European Networks, 11, pp. 178-179.
Bomke, P. (2015). Tracking down the effect of resilience – a systemic view helps, in: https://www.openaccessgovernment.org/tracking-effect-resilience-systemic-view-helps/19212/ (downloaded on 03/31/2016)
Brosius, H.-B. (1991). Schema-Theorie – ein brauchbarer Ansatz in der Wirkungsforschung. Publizistik, 36 (3), pp. 285-297.
D’Andrade, R. (1987). A folk model of the mind. In D. Holland & N. Quinn (Editor), Cultural Models in Language and Thought (pp. 112–148). Cambridge: Cambridge University Press.
Hurrelmann, K. & Richter, M. (2013). Gesundheits- und Medizinsoziologie (8th revised edition). Wennheim & Basel: Beltz Juventa.
Lindland, E. H. & Kendall-Taylor, N. (2012). Sensical translations: Three case studies in applied cognitive communications. Annals of anthropological practice, 36, pp. 45–67. DOI:10.1111/j.2153-9588.2012.01092.x
Mandery, M. & Bomke, P. (2015). Der richtige Rahmen. GesundheitsWirtschaft, 9(4), pp. 36-37.
Matthes, J. (2007). Framing-Effekte. Zum Einfluss der Politikberichterstattung auf die Einstellungen der Rezipienten. München: Verlag Reinhard Fischer.
Scheufele, B. (2006). Frames, schemata, and news reporting. Communications, 31 (1), pp. 65-83.
About the co-authors; Eva Baumann, PhD, Professor of Communication Studies at Hanover University of Music, Drama, and Media | Department of Journalism and Communication Research | Hanover Center for Health Communication
Mareike Schwepe, B.A., Student Assistant at Hanover University of Music, Drama, and Media | Department of Journalism and Communication Research | Hanover Center for Health Communication
The Hanover Center for Health Communication is a member of the ‘The Palatinate Region Braces Itself/You – Roads to Resilience‘ initiative.
1 Hurrelmann & Richter, 2013, p. 14
2 Mandery & Bomke, 2015, p. 37
3 Bomke, 2015
4 Bomke & Kendall-Taylor, 2014, p. 179
5 e.g. Brosius, 1991; Scheufele, 2006
6 D’Andrade, 1987, p. 112
7 Matthes, 2007
8 Lindland & Kendall-Taylor, 2012, p. 49
Pfalzklinikum für Psychiatrie und Neurologie, AdöR
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