For more than a century those dealing with the mental disorders of human beings have been trying to assure us that their work is objective, based on evidence and should enjoy the same status as the work of the mainstream medical profession. Indeed in order to progress their case they have sought to highlight the parallels between disorders of the mind and disorders of the body.
Of course one of the major the difficulties that they have encountered is the problem that much of their work and particularly their diagnostics has been very subjective. A study by the psychologist Philip Ash published in 1949 showed that psychiatrists presented with exactly the same information about the same patient agreed on a diagnosis only about 20% of the time. A similar study published in 1962 indicated that at their best psychiatrists reached the same diagnosis in a disappointing 42% of cases.
As a result of such outcomes those dealing in the area of so-called mental illness became eager to find ways to present their field of knowledge as having the same legitimacy as physical medicine.
Of course there have always been dissenters. One of the most notable was the Hungarian born psychiatrist Thomas S Szasz. Szasz was sceptical of the medical model being applied to psychiatry.
He wrote. “Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.”
Szasz argued the medical model could rarely be applied to psychiatry because except for some conditions (eg Alzheimer’s disease) there was little evidence that organic abnormalities of the brain were linked to what psychiatrists termed mental illness.
Further he wrote, “The concept of illness, whether bodily or mental, implies deviation from some clearly defined norm. In the case of physical illness, the norm is the structural and functional integrity of the human body. Thus, although the desirability of physical health, as such, is an ethical value, what health is can be stated in anatomical and physiological terms. What is the norm deviation from which is regarded as mental illness? This question cannot be easily answered. But whatever this norm might be, we can be certain of only one thing: namely, that it is a norm that must be stated in terms of psycho-social, ethical, and legal concepts. For example, notions such as “excessive repression” or “acting out an unconscious impulse” illustrate the use of psychological concepts for judging (so-called) mental health and illness. The idea that chronic hostility, vengefulness, or divorce are indicative of mental illness would be illustrations of the use of ethical norms (that is, the desirability of love, kindness, and a stable marriage relationship). Finally, the widespread psychiatric opinion that only a mentally ill person would commit homicide illustrates the use of a legal concept as a norm of mental health. The norm from which deviation is measured whenever one speaks of a mental illness is a psycho-social and ethical one. Yet, the remedy is sought in terms of medical measures which — it is hoped and assumed — are free from wide differences of ethical value. The definition of the disorder and the terms in which its remedy are sought are therefore at serious odds with one another. The practical significance of this covert conflict between the alleged nature of the defect and the remedy can hardly be exaggerated.”
“In actual contemporary social usage, the finding of a mental illness is made by establishing a deviance in behavior from certain psychosocial, ethical, or legal norms. The judgment may be made, as in medicine, by the patient, the physician (psychiatrist), or others. Remedial action, finally, tends to be sought in a therapeutic — or covertly medical — framework, thus creating a situation in which psychosocial, ethical, and/or legal deviations are claimed to be correctible by (so-called) medical action. Since medical action is designed to correct only medical deviations, it seems logically absurd to expect that it will help solve problems whose very existence had been defined and established on nonmedical grounds. I think that these considerations may be fruitfully applied to the present use of tranquilizers and, more generally, to what might be expected of drugs of whatever type in regard to the amelioration or solution of problems in human living.”
Szasz argued that the aberrant behaviours displayed by those unfortunates who were described as “mentally ill” were largely coping strategies that they had developed to deal with what he termed the “problems of living”. As a consequence whilst he didn’t believe that people shouldn’t seek therapy or that therapists didn’t provide a valuable service, but that the service was not properly speaking, a medical one. The illnesses that psychiatrists claimed to treat were not valid and most of the patients, strictly speaking, were not sick.
[As an aside Szasz famously said, “If you talk to God, you are praying; If God talks to you, you have schizophrenia.”]
The problems manifesting from the rather arbitrary and subjective diagnosing of mental illness appeared to be solved when the American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. This manual collated all the known mental disorders along with their symptoms in such a way as to encourage a uniformity in diagnosis. This was immediately embraced by professionals working in the mental health arena and they began to believe that with the manual’s help they could claim their processes were just as rigorous as those of the medical profession.
There were still of course some sceptics. Their arguments went along the following lines.
If I present to a doctor and I have a high temperature, congestion on my lungs, I am coughing and so on, the Doctor will more than likely diagnose I have a chest infection and prescribe some antibiotics.
If I present to a psychiatrist and I complain of melancholia, languor and lethargy, difficulty sleeping, anhedonia perhaps manifested by little interest in eating or sex I will likely (if the symptoms have been present for a few weeks) be diagnosed as having depression. My psychiatrist will probably prescribe a selective serotonin reuptake inhibitor (SSRI).
At first glance we might believe these are similar outcomes thus showing that psychiatry works in a similar way to conventional medicine. But do they? The doctor observing my chest infection knows that it has been caused by a strain of bacteria and clinical trials and documented evidence over many years would suggest that the appropriate antibiotic will be effective in eliminating the agent causing the illness. The psychiatrist on the other hand has at best a vague idea about what is happening in my brain to cause my malaise. When he prescribes the particular SSRI he has little knowledge about how it might work or if indeed it will work.
Prof Irving Kirsch from the University of Plymouth after fifteen or more years of research in the area has evidence to suggest that antidepressants (including SSRI’s) have little more efficacy than placebos.
At a presentation I attended a few years ago Kirsch had this to say. “The companies claim that the effectiveness of antidepressants has been proven in published clinical trials showing that the drugs are significantly better than placebos. But a close look at the data tells a different story. Although many depressed patients improve when given medications, so do many who are given a placebo, and the difference between the drug response and the placebo response is not that great. Most of the effects of antidepressant treatment seem to be due to the placebo effect. Furthermore the published trials are only the tip of the iceberg of material that doesn’t see the light of day. There are also clinical trials that have been withheld from publication. These are studies that have failed to show a significant benefit from taking the actual drug. When all the data are combined – published and unpublished – the inescapable conclusion is that antidepressants may be little more than active placebos, drugs with very little specific therapeutic benefit, but with serious side effects.”
But notwithstanding these concerns the DSM is now in its fifth edition. It has been considerably revised over the years both with regard to what is regarded as a mental illness and with respect to the representative symptoms. With regard to the former the initial publication for example included homosexuality as a mental illness. That, of course, has now been removed, largely as a result of rallies and protests held by the gay community. (This of course resulted in the sceptics protesting that the manual could hardly be claimed as science based if its results were subject to change as a result of protests because it offended minorities and not for any scientific reason!)
But overall there have been few “mental illnesses” removed and far more added. Each edition has seen added various syndromes and disorders that seem less like mental illnesses and more like ways of categorizing normal human behaviour as opportunities for markets for drug companies.
I suppose at some stage we need to agree on just what is “normal” human behaviour. For example if I go to my psychiatrist with the symptoms I mentioned above he/she more than likely will say I have depression. But if I presented myself after the loss of a close loved one he would most likely say my behaviour was normal and that I was merely grieving. Thus a set of symptoms that under one circumstance indicate a mental disorder under another do not.
A further criticism of the DSM approach to mental illness is that diagnosis has been reduced to a mere clerical function. A perfunctory chat with the patient allowing the appropriate boxes to be ticked is all that is required for a diagnosis. There is no need to engage with the patient as a distressed human being and bring to bear empathy along with a comprehensive understanding of human behaviour.
The psychologist and author, Gary Greenberg in his book Manufacturing Depression wrote, “Doctors, in other words, are too busy diagnosing patients to worry about whether or not they are really sick!”
Another problem with the way mental illness is viewed is that we seem only able to admit that people are mentally Ill or they’re not, a rigid dichotomy that in fact strays from the medical model. Dr William Glasser, obviously sharing some of the concerns of Thomas Szasz, identified this issue. Let me repeat what I wrote in a previous blog to illustrate this point.
Glasser, the founder of Reality Therapy, referring to the many patients he has dealt with that have no indication of brain pathology writes, “The most accurate way to describe these unhappy people is that, although they are not mentally ill, they are not nearly as mentally healthy as they would like to be.”. Whilst conceding that they may be benefited by counselling he continues, “I believe unhappy people can be taught to improve their own mental health…..”
Glasser believes that we fall into a trap when we try to draw parallels with physical and mental health. The problem is that we have been led to believe that only two states of health exist. We have come to believe we are either healthy or unhealthy. But this is demonstrably not true. The best way to describe physical health of the whole population, he suggests, is along a continuum:
Physically Ill——————-Out of Shape———————-Physically Healthy
Similarly, he suggests there is a mental health continuum:
Mentally Ill——————–Unhappy—————————Mentally Healthy
He asserts that, “The ‘mental illnesses’ that establishment psychiatrists diagnose, treat and list in DSM-IV (the Diagnostic and Statistical Manual of the American Psychiatric Association) should not be labeled illnesses because none of them is associated with any brain pathology.” He maintains that these “illnesses” are the many ways in which unhappy people express their unhappiness. Comparing the two continuums above, the mental equivalent of being “out of shape” physically, is being unhappy. Most times when we become aware of being out of shape physically, we know what to do – most likely to pay attention to our diet and to exercise. When we become aware we are out of shape mentally we present to a doctor steeped in the medical model who will take over responsibility for our unhappiness and probably prescribe drugs.
And I suppose we are encouraged in these ideas by the dictates of consumer capitalism. We are promised that if we take the appropriate drugs our lives will be restored to normalcy. But normalcy is not what the advertisements depict. “Normal” doesn’t mean an uninterrupted sense of well-being, let alone euphoria.
This is a point that in my book Froth and Goblets the Buddhist Augustus makes to the Princess Naomi. Let us join them in the palace gardens where Naomi is speaking.
“But I am not happy and I have experienced so much happiness lately that I had an expectation that it would ever continue thus.”
“Then you are mistaken. Our emotions come and go and even the wisest sage will have his equanimity challenged. Is there any land where the sky is forever blue? Is there any tree that flowers continuously? Is there a river that runs placidly in all its reaches? Is there a sea with no tides? This is the nature of things, a reflection of the impermanence and the constant change that underpins the universe. That is why the Buddha taught that we should become attached to nothing, not even happiness. The techniques we have learnt together will help you deal with your unhappiness and reduce the frequency of its occurrence, but do not believe it is possible to live forever happily.”
It seems to me that, in the face of the evidence, we should be cautious about trying to emulate the medical model when dealing with mental illness. Many of the aberrant behaviours that we treat as symptoms of mental illness we cannot as yet relate to organic conditions in the brain. Where chemical treatments work we are largely ignorant of the mechanisms. The push to transpose the medical model onto mental illness has largely been driven by an attempt by those working in the field to add more legitimacy to their practice or profession. No doubt this has been aided and abetted by drug companies trying to assert that their products are just as efficacious in alleviating mental illness as they have been successful in conventional medicine and therefore creating new and lucrative markets. The trend has also been helped by what one could only describe as a noble motive as well, and that is to destigmatise mental illness. Society seems more forgiving of our abnormal behaviour if we can link it to a disease.
As I have previously written It is difficult to know how many of these unfortunate people are merely “unhappy” as per Glasser’s categorisation above and need some assistance in finding more constructive ways of dealing with the world or have conditions that are severe enough to need treatment by drugs. The only thing we can be assured of is whichever category they might fit into, they are more than likely to be co-opted into the medical model and more than likely rendered passive victims under the paternalistic purview of a doctor whose only perceived option is the administration of drugs. As for the DSM, until such time as we are able to link aberrant human behaviour with brain pathology it does little more than provide convenient labels to groups of behaviours without any real explanatory value at all.