How should mental distress be treated?
Anxiety, Panic Disorder, Depression, Phobias and Obsessive Compulsive Disorders (OCD's) are described as common mental health problems. Mind (2019), say 1 in 6 people in England report experiencing at least one in any given week.
Deciding how to treat mental distress is a growing debate and filled with controversy.
The mental health system includes professionals, academics, service users, and clients, who all have access to mental health services and shape ideas about mental health practices. Distinguishing the various approaches can help demystify the type of help available and highlight some of the conflicts in psychiatry. Clues to the various models, approaches and views are in the terminology:
The biomedical approach is typically used by Psychiatrists, who provide diagnoses and administer medical treatment and pharmaceutical drugs.
Psychological or psychotherapeutic approaches are often used by Counsellors and Psychotherapists and cover a range of different talking therapy approaches.
Social approaches most commonly come from Social workers and Heath care workers, who give non-medical support that tackles social exclusion and promotes inclusion and non-discrimination.
Psychosocial is a prevalent stance adopted in today's world, considering psychology and the social model in mental health and wellbeing practice.
Biopsychosocial: This is often used in mental health academic research as it adopts a view that considers Biological, Psychological and Social approaches and factors.
Are we striving towards Mental Health Treatments that promote Autonomy or issues of Power and Control?
The two broad perspectives that often disagree come from 'progressive' and 'anti-psychiatry views. Foucault (1967) was an influential critic of psychiatry. He believed psychiatry was a way of controlling norms and terminology that talks about insanity in a way that is objective and separate from the implicit (Jones, 2020, p25). In contrast, medical researchers advocate research and advancements in medicine and support the medical psychiatry movement. History has a lot to answer for Jones (2020) invites us to think critically about how history can help us evaluate where different perspectives surrounding pro and anti views of medical approaches to mental health treatments have come from. In the pre-asylum era, mental disorders were treated as physical ailments. Insanity was linked to criminal behaviour. Treatment was restricted within unregulated private mental institutions; there was little regard for the people who were often subjected to harsh restraint and beatings. Older terms for mental problems were madness and lunacy; these words are offensive today and sometimes associated with schizophrenia (Jones, 2020, pp6-7).
The 1744 Vagrancy Act meant mental institutions were responsible for pauper lunatics, providing shelter and care for homeless people when it was illegal for them to sleep rough. The Madhouse Act in 1774 made it mandatory for mental institutions to be regulated and supervised. William Tuke and his family set up the York Retreat in 1792 to promote moral treatment (an idea that insanity might be cured by providing quiet space and respective interaction). Moral treatment formed the belief that not all disorders were physical; some were psychological. Mechanical restraints were ceased (Jones, 2020 pp30-31). Moral treatment resonates with the talking therapies (providing a safe space for people to explore and reflect on their issues) widely available for treating mental distress today.
'Psychiatry' describes the specialist branch of medicine concerned with the treatment of mental illness, typically associated with the medical model and was professionally established under the Association of Medical Officers of Asylums and Hospitals for the Insane in 1841. The Lunacy and Asylum Act in 1845 mandate all local authorities to build an asylum to serve the needs of 'pauper lunatics' in their area.
By the eighteenth century, psychiatry was a dominant force in treating mental illness. MacDonald described this as a disaster for the insane' as they became subject to crueller treatments and 'confined to mental institutions. Arguably, this giving rise to the whole medical model debates around care vs control.
Moral insanity described as a mental disorder linked to criminology and violence, and Prichard (1835) wrote a treatise on disorders affecting the mind. His work was significant from a progressive diagnostic perspective. Moral insanity, later known as a personality disorder (Jones, 2020 pp33-35), potentially links to debates around diagnostic labelling and reductionism and holism, thus highlighting different perspectives and approaches to treating mental health.
Charles Darwin published his Origin of the species in 1859 and made a significant impact on psychiatry. Darwin made the distinction that underclass people were branded as having heritable criminological tendencies. An important consequence was a significant move from the psychological realm and more attention towards other professions to heal the mind. There became a noticeable split between the medical model approach and psychoanalytical and psychological approaches, Freud's Psychoanalytical being the first (Jones, 2020 p33). Also, it highlights debates around social class and mental distress.
The word asylum became less favourable to the growing psychiatric profession. The 1841 establishment changed its name in 1887 to the 'Medic psychological Association of Britain and Ireland'. By the 20th century, asylums were called psychiatric hospitals (Jones, 2020 p26).
The post-asylum era began in 1950. Political pressures began to mount in the UK; asylums were in a desperate state. They became overcrowded and underfunded. And, this highlighted different perspectives, which offered two possible explanations: one, the discovery of new pharmaceutical drugs enabled people to function in society. The other is cost control due to overcrowding, the truth is uncertain, but political activist groups highlight the intentions of commercial interests revealing conflicts in interest (Jones, 2020 pp35-36).
The mental patients' union, the 1970s helped people diagnosed with mental health problems campaign, illustrating how patients had no voice at that time. It was not until the Representation of the People Act, 1983, that psychiatric patients in the UK could vote. In 1990 community policy led to survivors speaking out. The Service-user movement began as a way of contesting oppressive psychiatric practices and views, now includes a unique way of understanding through experience (Lomani, 2020 pp50-51). Human rights activists believe people should have more direct involvement in decisions that lead to policy and political change, 'nothing about us without us' took action on April 5, 1977, to demonstrate strong views about this. Formal structures to enable co-production began around 1996. The National Institute for Health Research established a government-funded patient participation and involvement group through 'INVOLVE'. PPI became a formal policy requirement in mental health settings (Department of Health, 2005).
Rosie (2018) mentions the damaging effects of just paying people lip service. It can be highly re-traumatising for service users who participate in co-production, and tokenism needs to be avoided at all costs because it is counterproductive. However, people's voices matter, and if the survivor movement is to continue with the aim of having an independent voice, then there needs to be a consistent effort to find ways to do this (Lomani, 2020 pp60-65).
Diagnosis raise concerns, particularly the role the pharmaceutical industry has on psychiatry. Commercial interests are controversial in the private or public healthcare sector and attract political interest on various topics. Allen Frances (2012) clarifies that diagnosis almost always leads to medication prescribing, which tips the power balance towards commercial interests. Dr Frances discusses diagnostic inflation and considers the question: Does everyone have a mental illness? Frances thinks the DSM-V and the UK equivalent ICD-10 will lead to millions of people being mislabelled with mental disorders. According to Goffman E (1963), people who become labelled are open to being stigmatised, and they learn to believe there is something wrong with themselves. He describes this as a 'spoiled identity. In this process, the reaction of others spoils a normal perception of self (Jones, 2020 pp35-36). These types of issues also link to the massive debates around various approaches and the risk of harm.
Additionally, earlier versions of the DSM led to outrage when gay and lesbian activists campaigned to de-medicalise homosexuality. Feminists also criticised the inclusion of Premenstrual Dysphoric Disorder (PMDD). Researchers have argued that this pathologising leads to medication and side effects. On the other hand, the medicalisation of Post Traumatic Stress Disorder (PTSD) was welcomed by activists for Vietnam veterans, as they were not adequately diagnosed (Harper, 2020, p110), acknowledging both sides of common debates around diagnosing mental health problems.
Considering the historical timeline of movements in psychiatry can shine a light on the different approaches available for treating mental distress today and can help us evaluate which is the most suitable form of help for us. Today we have a much more diverse approach to psychiatry and mental illness than we have ever had in history.
There is a more significant effort towards collaboration and integrative approaches. The NHS long term plan (2019) support this idea. The Improving Access to Psychological Therapies (IAPT) is run by the NHS in England, offering NICE-approved therapies for treating people with mental health problems. The stepped care approach includes low intensity and high-intensity treatments for mild to severe mental health problems, the preferred choice being Aaron Beck's evidence-based Cognitive Behavioural Therapies model (CBT).
Other psychological approaches are popular within talking therapies; for example, Carl Rogers, humanistic (or person-centred) model, a popular approach that is particularly accessible through counselling and psychotherapy within private therapy and third sector, community counselling agencies. The humanistic approach resonates with moral treatment because it enables clients to be autonomous and is client-led. It is also used in integrative therapies, which utilise a few different approaches to suit individual needs.
History would indicate that psychiatry can potentially cause more harm than good. In England, many people rely on the NHS for health care. Regardless of well-meaning intentions, at certain times, the NHS become seriously underfunded. There are points in history where it is unclear what the motive for change has been, but often it rests in either cost control or a breakthrough in medicine. If we do not drive policy change, then potentially, power will rest in the hands of the medical model. Including pharmaceutical drug companies and some of the power struggles seen in history may repeat themselves. The voices of survivors illustrate conflicts of interest. Diagnostic labels can lead to misdiagnosis, and medication can have side effects, causing more harm than good.
In today's world, more choices are available for treating mental distress. Approaches such as talking therapies that adopt a humanistic model within the approaches specifically support and encourage people to find their Autonomy and ways to manage various problems. Medication is also an option, as is evidence-based Cognitive Behavioural Therapy (CBT) offered as the NHS treatment of choice. Accessing treatment can include Health and Social Care services, Private Therapy, Charity-Based organisations and Community-Based services. When choosing a good therapist through private organisations, or independent providers, it is important to do our research to ensure that the service is ethical and regulated to professional standards. I think it is fair to say that individuals know themselves best; some might feel a medical approach is necessary. In contrast, others might want to try other approaches, such as person-centred, holistic, psychological, talking therapies or social approaches. Other's might seek therapies to complement medicine for something they recognise and relate to as an illness.
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