Psychiatry
We start with psychiatry because it has been the dominant discourse. Accordingly, it has shaped the views of others or has provoked alternative or opposing perspectives. While psychiatric patients (Rogers et al. 1993) and those in multi-disciplinary mental health teams (Colombo et al. 2003) evince a complex range of views about the nature of mental disorder, each of these models competes for recognition and authority alongside the traditional and dominant medical approach deployed by psychiatry.
Psychiatry is a specialty within medicine.
Its practitioners, as in other specialties, are trained to see their role as identifying sick individuals (diagnosis), predicting the future course of their illness (prognosis), speculating about its cause (aetiology) and prescribing a response to the condition, to cure it or ameliorate its symptoms (treatment). Consequently, it would be surprising if psychiatrists did not think in terms of illness when they encounter variations in conduct which are troublesome to people (be they the identified patient or those upset by them). Those psychiatrists who have rejected this illness framework, in whole or in part, tend to have been exposed to, and have accepted, an alternative view derived from another discourse (psychology, philosophy or sociology).
As with other branches of medicine, psychiatrists vary in their assumptions about diagnosis, prognosis, aetiology and treatment. This does not imply, though, that views are evenly spread throughout the profession, and as we will see later in the book, modern Western psychiatry is an eclectic enterprise. It does, however, have dominant features. In particular, diagnosis is considered to be a worthwhile ritual for the bulk of the profession and biological causes are favoured along with biological treatments.
This biological emphasis has a particular social history
However, this should not deflect our attention from the capacity of an illness framework to accommodate multiple aetiological factors. For instance, a psychiatrist treating a patient with antidepressant drugs may recognize fully that living in a high-rise flat and being unemployed have been the main causes of the depressive illness, and may assume that the stress this induces has triggered biochemical changes in the brain, which can be corrected by using medication.
Specific key points extracted from the text provided, focusing on the illness framework in mental health services, are highlighted below.
Illness Framework Dominance: The illness framework dominates mental health services because, at an institutional level, psychiatry is the dominant profession. This dominance does not imply conceptual superiority.
⦁ Strengths of the Illness Framework include:Neurobiological evidence also supports the idea, linking specific bacteria and viruses, such as syphilis and encephalitis, respectively, to mental disorders. Clinical observations of individuals with temporal lobe epilepsy show a connection between neurological conditions and mental health disorders.
⦁ Limitations of the Illness Framework:A large percentage of what is classified as ‘mental illness’ has no known biological basis within the considerable amount of research done to date. Conditions such as anxiety neuroses, reactive depression, and functional psychoses—such as schizophrenia and major depression—do not have understandable biological origins in spite of much research.
⦁ Genetic and Familial Considerations:Although there is certainly some evidence of genetic susceptibility to some types of mental health problems, this association is by no means strong enough to support claims of a direct biological origin. Environmental factors, such as upbringing, may also play a crucial role in the development of these conditions.
⦁ Critique of Biological Treatments:The effectiveness of biological treatments (e.g., electroconvulsive therapy, major tranquilizers) does not necessarily prove biological causation. Symptoms can be alleviated without establishing a direct cause.
Analogies are drawn in explaining how symptom alleviations are not understood in terms of their causes.
⦁ Symptoms versus Signs:Where the illness framework is about symptoms, thus subjective experiences, rather than objective signs or even observable physical changes. In psychiatry, a diagnosis is more often based on communication and behavior rather than on any measurable biological indicators, as in many illnesses.
Critique of Mental Illness as a Concept:
Thomas Szasz insists that mental illness is a myth, and only physical ailments exist as literal things, whereas mental disturbances exist metaphorically. Nevertheless, such physical disturbances do have considerable psychological effects, showing the interdependence of the psyche with the body.
⦁ Psychosomatic illnesses: It is also well documented that emotional distress acts as a precursor to a number of psychosomatic conditions, such as peptic ulcers and cardiovascular ailments, suggesting an interdependence of mind and body.
These are the key points of the discussion on dominance, strengths, limitations, and critiques of the illness framework being considered in the context of mental health.
Psychoanalysis
Psychoanalysis was the invention of Sigmund Freud. It has modern adherents who are loyal to his original theories but there are other trained analysts who adopt the views of Melanie Klein; others take a mixed position, borrowing from each theory. Thus, psychoanalysis is an eclectic or fragmented discipline. Its emphasis on personal history places it in the domain of biographical psychology.
Indeed, Freud’s work is sometimes called depth or psychodynamic psychology, along with the legacies of his dissenting early group such as Jung, Adler and Reich. Depth psychology proposes that the mind is divided between conscious and unconscious parts and that the dynamic relationship between these gives rise to psychopathology.
Like other forms of psychology, psychoanalysis works on a continuum principle – abnormality and normality are connected, not disconnected and separate. To the psychoanalyst we are all ill to some degree. However, the medical roots of psychoanalysis and the continued dominance of medical analysts within its culture have, arguably, left it within a psychiatric, not psychological, discourse.
It still uses the terminology of pathology (‘psychopathology’ and its ‘symptoms’); assessments are ‘diagnostic’ and its clients ‘patients’; people do not merely have ways of avoiding human contact, they have ‘schizoid defences’; and they do not simply get into the habit of angrily blaming others all of the time, instead they are ‘fixated in the paranoid position.
Psychology
Because psychology, as a broad and eclectic discipline, focuses, in the main, on ‘normal’ conduct and experience, it has offered concepts of normality as well as abnormality. Buss (1966) suggests that psychologists have put forward four conceptions of normality/abnormality:
1. the statistical notion.
2. the ideal notion.
3. the presence of specific behaviours.
4. distorted cognitions.
Statistical notion
The statistical notion simply says that frequently occurring behaviours in a population are normal so infrequent behaviours are not normal. This is akin to the notion of norms in sociology. Takeas an example the tempo at which people speak. Up to a certain speed, speech would be called normal. If someone speaks above a certain speed they might be considered to be ‘high’ in ordinary parlance or ‘hypomanic’ or suffering from ‘pressure of thought’ in psychiatric language. If someone speaks below a certain speed they might be described as depressed. Most people would speak at a pace between these upper and lower points of frequency.
A question raised, of course, is who decides on the cut-offs at each end of the frequency distribution of speech speed and how are those decisions made? In other words, the notion of frequency in itself tells us nothing about when a behaviour is to be adjudged normal or abnormal. Value judgements are required on the part of lay people or professionals when punctuating the difference between normality and abnormality. Also, a statistical notion may not hold across cultures.
In spite of these conceptual weaknesses, the statistical approach within abnormal psychology remains strong. Clinical psychologists are trained to accept that characteristics in any population follow a normal distribution and so the statistical notion has a strong legitimacy for them. This acceptance of the normal distribution of a characteristic in a population means that in psychological models there is usually assumed to be an unbroken relationship between the normal and abnormal. However, this notion of continuity of, say, everybody being more or less neurotic, may also assume a discontinuity from other variables.
Ideal notion
There are two versions of this notion: one from psychoanalysis and the other from humanistic psychology. In the former case, normality is defined by a predominance of conscious over unconscious characteristics in the person (Kubie 1954). In the latter case, the ideal person is one who fulfils their human potential (or ‘self-actualizes’). Jahoda (1958) drew together six criteria for positive mental health to elaborate and aggregate these two psychological traditions:
1. balance of psychic forces.
2. self-actualization.
3. resistance to stress.
4. autonomy.
5. competence.
6. perception of reality
The problem is that each of these notions is problematic as a definition of normality (and, by implication, abnormality). The first and second are only meaningful to those in a culture who subscribe to their theoretical premises (such as psychoanalytical or humanistic psychotherapists). The resistance-to-stress notion is superficially appealing, but what of people who fail to be affected by stress at all?
We can all think of situations in which anxiety is quite normal and we would wonder in such circumstances why a person fails to react in an anxious manner. Indeed, the absence of anxiety under high-stress conditions has been one defining characteristic of ‘primary psychopathy’ by psychiatrists.
Identification of Specific Behaviors
The emergence of psychology as a scientific academic discipline was closely linked to its attention to specifiable aspects of conduct. It emerged and separated from speculative philosophy on the basis of these objectivist credentials. Behaviourism, the theory that tried to limit the purview of psychology to behaviour and eliminate subjective experience as data, no longer dominates psychology but it has left a lasting impression. Within clinical psychology, behaviour therapy and its modified versions are still common practices. Consequently, many psychologists are concerned to operationalize in behavioural terms what they mean by abnormality.
The terminology of specific behaviours still raises questions about what constitutes ‘maladaptive’. Who decides what is ‘unwanted’ or ‘unacceptable’?
One party may want a behaviour to occur or find it acceptable but another may not. In these circumstances, those who have more power will tend to be the definers of reality. Thus, what constitutes unwanted behaviour is not self-evident but socially negotiated. Consequently, it reflects both the power relationships and the value system operating in a culture at a point in time.
Altered Cognitions
The final approach suggested by Buss emerged at a time when behaviourism was becoming the dominant force within the academic discipline. However, during the 1970s this behavioural emphasis declined and was eventually displaced by cognitivism. As a result, psychologists began to treat inner events as if they were behaviours (forming the apparently incongruous hybrid of a ‘cognitive-behavioural’ approach to mental health problems) or they increasingly incorporated constructivist, systemic and even psychoanalytical views (e.g. Bannister and Fransella 1970; Guidano 1987; Ryle 1990).
Some of whom were psychiatrists, not psychologists, offering a pragmatic and a-theoretical approach to symptom reduction (e.g. Beck 1970; Ellis 1970; Pilgrim and Carey 2010). Since the outline by Buss was offered, we can also note that in the field of mental health humanistic psychology has become more evident as a political force, within clinical psychology, counselling psychology and psychotherapy. Humanistic psychology emphasizes the inherent capacity of human beings to seek and find meaning, including during periods which are distressing for people. Humanistic psychology emerged from North American philosophy (William James and James Dewey) and was developed in the field of mental health by Abraham Maslow, Carl Rogers and Rollo May.
It has affinities with European existentialism, which joined humanistic approaches to mental health problems in anglophone countries with the work of existential psychiatry (especially from Victor Frankl and Ludwig Binswanger) after the Second World War. A particularly important variant of humanistic psychology has been that of ‘positive psychology’, which emphasizes strengths and solutions rather than deficits and problems (the dominant tradition in clinical work) (Ryan and Deci 2001). Psychology is thus a highly variegated discipline and this diverse character is at its most obvious in relation to the wide range of psychological approaches to mental health problems.
Discussion
The four ways of viewing service users described in the second part of this chapter illustrate the construction of the mental patient from different vantage points. The first, of patient, has a narrow clinical conception of the user of services – as an extension or carrier of the mental illness he or she is deemed to be suffering. The conceptualization of the user as consumer defines the user of services as a whole person, who has needs over and above those defined from a diagnostic viewpoint.
This approach tends still to be professionally defined and is limited to the parameters of the provision and delivery of existing or achievable services. It also contains the contestable assumption that service users ‘consume’ products that are aligned with their expressed needs. The third approach takes those expressed needs as the main reference point of analysis, along with the collective structural position of mental patients within a wider social context.
