Rebalancing the approach to mental health

Fri, Dec 29, 2006 Irish Times

To understand the issues surrounding psychiatric treatment, we need to get beyond the drugs versus therapy argument, write Pat Bracken and Marcellino Smyth.

The recent debate about mental illness and how it is to be understood and treated is to be welcomed. Indeed, it is what Minister of State Tim O'Malley called for in the first place. However, if we are to move forward, we need to get beyond arguments about "drugs bad, therapy good" or vice versa. We believe that underlying the discussion are two frameworks for understanding mental health and its problems. Identifying these frameworks and the different ideas they represent might help us get to a stage where we are at least clear about what it is we disagree on.

Underlying one set of arguments is what has been called (for good or bad) the "medical model". In essence, this works with the assumption that problems in areas of our lives such as thinking, feeling, relating and behaving are best understood through a medical idiom involving a vocabulary of symptoms, diagnosis, aetiology and prognosis.

It is not simply about using medication instead of psychotherapy and its proponents sometimes use the term "bio-psychosocial" in an attempt to make it seem more inclusive.

What is really at stake is the belief that the same sort of causal logic that helps explain problems with our livers, kidneys and nervous systems can be applied equally well to the mental sphere. This has implications for academic agendas and most psychiatric research is committed to this sort of logic.

While those who promote this model do not ignore questions to do with meanings, relationships and values, these are understood to be secondary concerns. For professionals who are trained to see the world through "medical-model" spectacles, problems with feelings, thoughts and behaviours are constructed as "symptoms" that are then analysed in terms of "clinical syndromes" and responded to with a treatment of one sort or another.

This approach has always had its critics, many of them psychiatrists like ourselves.

It has been pointed out that when we use the term "mental illness" we are implying that we are dealing with something that is different in certain ways to other forms of illness. The word "mental" points to the fact that when we are dealing with thoughts, beliefs and relationships we have moved to a territory that is qualitatively different to the world of neurones, hormones and genetics. We have moved to a world where meanings are central, a world that very often resists explanation in the causal logic of medical science.

This is also a world where relationships between patients and those who are offering help are often of more importance than the treatment that is being delivered.

It has been known for many years that the quality of the therapeutic relationship is a stronger predictor of effectiveness than the particular form of therapy being used. Trials of antidepressants have underscored the importance of the placebo response. This in turn is based on relationships that can generate a sense of meaning and hope.

In recent years, an alternative to the medical model has emerged from the work of service users and professionals in various parts of the world. With a focus on the idea of "recovery", this puts questions of meanings, relationships and values at the centre; they are no longer secondary.

According to the UK-based organisation Rethink: "Recovery is about people seeing themselves as capable of recovery rather than as passive recipients of professional interventions. Out of adversity has come change, personal development and growth."

While it is not anti-medication or anti-medical, this model refuses to privilege the medical vocabulary and seeks to endorse the validity of different perspectives on mental health.

It argues that while at times it might be helpful to regard experiences such as depression, fearfulness, self-harm and hearing voices as "symptoms", there is no independent scientific authority that can pronounce that this is always the best way of framing such experiences.

Indeed, this perspective also maintains that a limited medical framing of an individual's problems can often serve to undermine moves towards recovery.

The "recovery agenda" is gathering strength across the world as service users become stronger and more powerful. There is now an established academic discourse based on these ideas.

In Ireland, the recent report of the expert group on mental health policy, A Vision for Change, makes the case that this orientation "should inform every aspect of service delivery". As practising psychiatrists, we welcome this. As doctors, we are very conscious that humans are "embodied beings" - that our minds are wrapped up in our bodies. We are very aware that there is often a biological dimension to states of madness, distress and alienation. We use medication in an attempt to relieve the suffering of these states of mind.

However, we are also aware that many of the problems we encounter involve complex human situations that deny easy formulation in a medical vocabulary. This can be the case with patients struggling with psychotic experiences just as much as those with anxiety or depression.

Psychiatry is not just a branch of neurology. While neuroscience is important in mental health, it is far from the full picture. There is growing concern within the discipline that the past decade has seen too much focus on biological aspects of mental illness and the neglect of other equally important issues.

We believe that psychiatrists can work easily with a "recovery orientation". However, to do so we will have to move beyond the confines of the traditional medical model, work with services that can provide for genuine choice and actively collaborate with service users and their organisations.

Dr Pat Bracken and Prof Marcellino Smyth are consultant psychiatrists with the West Cork Mental Health Service, based at Bantry General Hospital

© 2006 The Irish Times