The Return of the "Ideological Disputes".

A while ago I wrote a blog about a report from the Schizophrenia Commission. The report, entitled "The Abandoned Illness", argued that those with a diagnosed psychotic disorder were being let down by a broken and demoralised system. But that is not what I'm going to concentrate on here. Rather, it is just one small part of that report that has got my attention this time, for in it, the head of the Commission, Professor Sir Robin Murray, stated that the days of the "ideological disputes" which had surrounded mental health had now gone. The disputes to which he refers were, I believe, to do with whether mental illness is better viewed as being caused by biological, or environmental/social/personal, factors, and Murray argued that it was now understood that both biological and social factors had a role in mental ill health.
However, in "The Observer" newspaper on 12th May, it was reported that the British Psychology Society's division of clinical psychology were going to issue a statement declaring that it was time for a "paradigm shift" in how mental illness is predominantly understood. Dr Lucy Johnstone, a consultant clinical psychologist who helped draw up the statement, said it was unhelpful to see mental health issues as illnesses with biological causes, and went on to sate: "On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances - bereavement and loss, poverty and discrimination, trauma and abuse". The statement, then, throws doubt on the biomedical model which is the current psychiatric orthodoxy.
Also, it has been made at an opportune time, being issued just before the release of the DSM-5, the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders". Although not used in Britain (which uses the "International Classification of Diseases" (ICD) published by the World Health Organisation), the DSM is still hugely influential and, indeed, controversial. This is because critics of the DSM think that it wrongly sees millions of people categorised as having mental disorders. For example, it claims that things such as shyness in children or temper tantrums are medical "problems" treatable with drugs. So, as the number of disorders in the manual increases, so this has led to claims that many of the "conditions" are simply inventions dreamt up for the benefit of pharmaceutical giants, or so-called "big pharma". Indeed, we at the Pathways Group often joke about what is the most outlandish diagnosis that has been invented, and I myself have often had doubts about why psychiatry seems insistent on "medicalising" normality.
However, there are some who insist that psychiatric diagnoses are still valid and useful. Professor Sir Simon Wessley, a member of the Royal College of Psychiatrists and chair of psychological medicine at King's College London, said that, "A classification system is like a map, and just as a map is only provisional, ready to be changed as the landscape changes, so does classification". He also argued that anyway, psychiatry is not wholly governed by the medical model, and does already take into account social and personal factors.
Indeed, if my own treatment is anything to go by, this seems to be the case, as I was always asked about my personal background and social situation. However, I would say that it did take rather a long time for me to receive a diagnosis which could explain all that I went through, and on one occasion, when I reported that I was not sleeping very well, the immediate reaction by mental health staff was to increase my medication. They did not ask if perhaps I would like to talk about my feelings, or if I would like to discuss what I felt was actually leading to my sleeplessness. This, then, to my mind, is one of the problems which a predominantly biomedical model can lead to, with patients, particularly with psychotic disorders, simply being medicated and then left alone.
So, it would appear that the "ideological disputes" surrounding mental ill health are alive and kicking, and one simply hopes that, whatever the outcome of such wrangling, treatment for those who find themselves unwell only improves.      


bazza said…
Hello David. This is a really interesting topic. I think that DSM is not only valuable to the pharmaceutical manufacturing industry in the USA but also to those wishing to claim on medical insurance. The more conditions that are diagnosed (and DSM now has many hundreds) the easier it is the make a claim and the more doctors can earn!
The other question you raise is absorbing as well; sometimes I wonder if it's useful to have the mental health and physical health sections of the NHS so clearly separate from each other.
Many people have a weakness which only manifests during times of crisis or stress, typically stomach or back pain. If you present to a GP with a stress-related somatic condition should that be seen as a mental illness? Obviously the lines are blurred.
Many sexual dysfunctions are also psycho-somatic. It's not a black-and-white question.
Thanks for a thoughtful and interesting post.
Dixie said…
Dear David,
At any given time, I might be 'saddled' with 3-7 different doctors, in various fields of health care. This appears to be the 'norm' for the diagnosis and ongoing care of Fibromyalgia.

In 2002 I was encouraged to chose a "lead physicican" to keep all others informed of my prognosis and progress. Basically every year I go for a general health physical, a spine examination, and an update to the psychologist. All updates are forwarded to my lead.

Before this method came along, from 1997-2002, life was chaotic. I was given overdoses of medicines and other horror stories I won't relay here. In short the saving grace was assigning a lead doctor.

I find Bazza's comment interesting as well, however outside of Fibromyalgia I have no experience to draw from. The physical, for me, has always seemed to proceed the emotional-mental factor. I could be wrong and that's why it's so interesting to visit here for your take on the various systems.

Thank you!

David said…
Hi bazza,
I'd never thought of the medical insurance angle that you mention, and the notion that the lines between mental and physical illness are blurred is an interesting one. In fact, I once went to a conference which broached the subject of the role of physical wellbeing in mental health. Many, it seems, with diagnosed mental health conditions like schizophrenia do not live as long as is the average, mainly due to them engaging in physically unhealthy behaviours and having poor access to doctors. This is slightly different to your take on psycho-somatic problems, but I thought you might find it interesting anyway! I'm just a wealth of information, bazza!
Very Best Wishes,
David said…
Hi Dixie,
Thanks for your take on the situation. You say that for you the physical has always preceded the mental/emotional. But, as I've said above, the mental/emotional can perhaps lead to physical probelems. It's an interesting thing to ponder, and I may make it the subject of a future post!
Thanks once again Dixie for your continued input and support. It's always a pleasure to read your comments!
Very Best Wishes,
klahanie said…
Hi David,

A thoughtful article and this time, because you have basically covered a lot of basis and with the input of Barry and Dixie, there's little I can add.

So just a short note. Although I know that medication is a necessity with some, the over-medicating, instead of being offered alternatives, other resources, was something that I endured in the past.

Kind regards,

David said…
Hi Gary, my hairy friend.
I suppose what you mention you endured in the past could be put down to psychiatry's current reliance on the medical model. If illnesses are viewed as mere chemical imbalances in the brain which can be corrected with medication, then being over-medicated, instead of being offered alternative therapies, can be a problem. As I mention in my post, I too, when I reported feeling a little unwell, was only met with the unsatisfactory solution of having my medication increased. Perhaps with this statement, the paradigm shift which many have wished to see for a while now will come to pass, and more alternative therapies besides medication will be offered to patients. I suppose we'll just have to wait and see, Gare!
Very Best Wishes,

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