Models of Madness

In prior posts I’ve written about the pros and cons of the medical model (psychiatry) as the predominant model for the treatment of mental illness, and about what I call “the model muddle.” Models are ways of organizing and framing ideas in a way that serves as a guide. A good model is like a good map: it helps you to get where you want to go. The map is not the territory, but merely a helpful representation. No model is perfect and complete, or demonstrably superior to all other models, in all situations. Each one has its flaws and limitations.

Psychiatry is the medical model’s methodology for treating mental illnesses – primarily with medications. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to an appropriate treatment.  The medical model is very good at what it’s good at, such as mending broken bones, doing surgery, and treating many physical ailments. But psychiatry is built more on theory than on scientific evidence.

One limitation of the medical model is that it’s mainly focused on what you do after you have symptoms, not so much on wellness and prevention. A distinct limitation of the medical model as regards mental disorders is that, unlike most common physical disorders, there are no identifiable biological markers to distinguish (for instance) what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psychodiagnosis is not rocket science, because mental illness isn’t measurable in the way that many physical illnesses are (i.e. medical science can distinguish between asthma and pneumonia). At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

Critics of psychiatry have argued that mental illness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. The negative side effects of some psychotropic medications and mood stabilizers outweigh the benefits for many patients. The term iatrogenic effects refers to treatments that do harm. Unfortunately, contemporary psychiatry is wedded to the pharmaceutical industry. That having been said, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need for primary reliance on drugs as the default treatment for psychopathologies.

The biopsychosocial model takes into account such factors as physical health, heredity, stress, social stigma, social support system, mental habits, chemical dependency,  economic status, nutrition, and homelessness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that gives people who’ve been labeled as mentally ill more autonomy and more options for resolving problems related to their mental health. Unfortunately, the national mental health system is severely underfunded, and many people in need of help are underserved. This is a national disgrace.

The recovery model is an alternative to the medical model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” substance abusers, but did it apply to the mentally ill? Many mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers/programs in some cities, that aren’t run on the medical model. Such programs don’t necessarily preclude psychiatric interventions, but also offer educational resources to empower patients, professional and peer support, and access to community resources, to reduce the stressors that exacerbate symptoms of mental illness.. The concept of recovery from mental illness doesn’t mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom remission and control of one’s life. To find out more about the recovery movement and alternatives to traditional psychiatric treatment, check out madinamerica.com.

Psychiatry: pro and con

I write this as someone who had a career as a psychologist in the mental health system, working within the scientific/medical model of psychiatric treatment. So, I’m not writing to reject psychiatry outright, but to examine its efficacy. I’ve written about the value and limitations of models in previous posts, and about what I call the “model muddle.” Models are just maps, helpful only to the degree that they’re accurate. No one model is demonstrably superior to all other models, in all situations. Every model has its limitations.

First, I’d like to distinguish between psychology, psychiatry and psychoanalysis. Psychology is the study of human behavior, and provides the basic theoretical structure for psychotherapy. Sigmund Freud came up with the concept of “the talking cure,” the notion that dialogue with a caring professional could help to resolve symptoms and treat psychopathology. Psychiatry is a branch of medical science, based on the concept that the accurate assessment of symptoms of mental illness can lead to an accurate diagnosis, which will result in an appropriate treatment. Psychiatrists are medical doctors who specialize in the treatment of mental illness. Freud was a psychiatrist, and psychiatrists who are trained in the system of Freudian psychotherapy are called psychoanalysts.

While I believe that psychiatric (medical model) treatment has helped a lot of people with debilitating metal and emotional symptoms, like any model, it has its limitations. Since the 1960s, the efficacy of psychiatric treatment has been questioned – with good reason. A primary critic was psychiatrist Thomas Szasz, who wrote The Myth of Mental Illness. Another psychiatric rebel was R.D. Laing, and yet another psychiatrist, David Cooper, coined the term “antipsychiatry.” Critics of psychiatry argue that mental illness/madness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. This core of criticism has led to the current antipsychiatry (alt. recovery) movement.

A primary criticism of psychiatry is that psycho-diagnosis isn’t rocket science. It’s imprecise relative to the diagnostic precision for most common physical medical conditions, and can be selective and subjective in its diagnostic criteria. Unlike with physical medical conditions that can be diagnosed by tests and procedures that reveal “markers” of a specific condition (i.e. pneumonia vs. tuberculosis), there are no such markers that distinguish schizophrenia from schizoaffective disorder or bipolar disorder. I’ve known many people with chronic mental and emotional disorders who have gotten a wide range of psychiatric diagnoses, over years of treatment. Ideally in the medical model, an accurate diagnosis results in appropriate and effective treatment. This is less often the case in psychiatry, because there’s more “educated guesswork” involved.

Proponents of the antipsychiatry movement contend that psychiatric treatment is all too often more damaging than helpful to patients. Extreme treatments such as prefrontal lobotomies haven’t proven to be effective; and the negative side effects of some psychotropic medications and mood stabilizers seem to outweigh the benefits for some patients. The term “iatrogenic effects” refers to treatments that do harm.

Another valid criticism of psychiatry is that it’s over-reliant on pharmaceuticals, and that the psychiatric profession has had incestuous ties to Big Pharma. I believe that, as a culture, we’re too dependent on medications as a panacea for health problems related to bad lifestyle choices. Drug company ads suggest that we can eat whatever we want and take pills to control any gastro-intestinal symptoms that result from a poor diet.

Having said that, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need to rely primarily on drugs as the default treatment for psychopathologies.

The concept of recovery from mental illness doesn’t necessarily mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom control or remission. There are recovery centers in cities around the country that offer alternatives to traditional psychiatric treatment, recognizing that community and peer support can be important components of treatment. Such programs don’t preclude psychiatric interventions, but don’t rely on them as the default mode.

Factors such as physical health, stress, social stigma, chemical dependency, poverty, homelessness and nutrition can all play a role in mental health and mental illness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that give people who have been labeled as mentally ill more autonomy and more options for resolving their problems.

You can find out more about the antipsychiatry movement, the recovery model, and alternatives to traditional psychiatric treatment at <madinamerica.com>.