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The rhetoric/reality gap in social determinants of mental health

Patrick Larsson (Chartered Counselling Psychologist, based at Homerton University Hospital NHS Foundation Trust, London, UK)

Mental Health Review Journal

ISSN: 1361-9322

Article publication date: 29 November 2013



The purpose of this paper is to establish that social determinants are vital contributing factors to mental health difficulties and that, similar to physical health, mental health follows a social gradient. Despite this acknowledgement, there is a rhetoric/reality gap found in social determinants of mental health (SDMH). It will be argued in this paper that this rhetoric/reality gap is located on a number of levels, including theoretical, methodological, practical, political and policy based, which are proposed here to be interrelated.


The approach is a conceptual analysis of the rhetoric/reality gap found in SDMH using a critical perspective. It draws on a wide variety of theories in order to provide an analysis of the issues outlined.


The paper's central finding is that there is a dissonance between the dominant ontological, epistemological and methodological, or axiomatic, focus in contemporary mental health theory and practice and SDMH. This dissonance has led to a form of “analysis paralysis” on all levels, and the initiatives required to tackle SDMH have been marginalised in favour of a narrow interpretation of evidence-based research and its accompanying ideology centring on the individual, which has established itself as a primary position on what constitutes valid knowledge to the detriment of other views.


The paper offers a critical perspective on an area of SDMH which is often alluded to but never explicitly explored, and questions the underlying assumptions inherent to mental health theory and practice. The paper's value is that it draws attention to this particular dilemma on a wider scale, including on a political and policy-based level, which is often neglected in mental health theory, and it makes some recommendations on how to move forward.



The views expressed in the paper are those of the author alone and not the employer.


Larsson, P. (2013), "The rhetoric/reality gap in social determinants of mental health", Mental Health Review Journal, Vol. 18 No. 4, pp. 182-193.



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