Tuesday, 19 January 2010

The medicalisation of Mind

I stumbled accross this debate, concerning the expansion of psychological therapies in the U.K.

To my surprise, at first, I found the argument for containing the mental health 'industry' compelling. I've often thought about this issue, particularly because I have bipolar disorder and take pills for it everyday.
I've thought 'would I be ill in another society?'. I'm not ill (most of the time) and I'm fairly confident I can attribute this to the medication. I'm very grateful to the NHS. But perhaps, if my culture was different, I might never have developed the condition, or it might never have been labelled an illness. I usually conclude that I would have had it (what with the genetics involved) and that if it wasn't labelled, it never would have got sorted and my quality of life would have suffered.
But what about everyone else? Is it possible that the mental health profession, with the best of intentions, wants to label more people than is necessary? Certainly it's possible, natural even, for a field to broaden its purveiw. The issue of prevelance is rightly contentious.
"If on average 1 in 4 or 6 of the people going about their ordinary business on the street outside my house as I write are diagnosable as ‘cases’ of mental illness, we need to re-examine our models before we examine the people" This seems to make intuitive sense, but intuition can be very misleading. Prevelence can be high without being immediately apparent of course (Chlamydia anyone?), but moreover classifying people as mental health 'cases' does not negate their personhood or agency, as the author suggests. It only identifies those that might benefit from treatment options. The value of a model lies in its use; it's a stastic that can gauge how much treatment capability might be provided, it doesn't itself demand that 1 in 6 must be treated.
However labels clearly can do more harm than good; if patients see their condition as immutable, or as an excuse to take advantage of the benefits system (which can itself reinforce the notion of total debilitation). This is where the argument against more diagnoses has most strength. This negative reinforcement clearly does happen, but I would say it is a failing of the quality of psychological advice and care, not as a direct result of the size of the psychological profession. This naive labelling often occurs when GPs are trusted with treatment decisions, because they can't refer to a better trained psychologist.
The author does coin a useful aphorism: 'citizens are on average as tough as the culture they are living in expects them to be.' I'm not sure of the evidence for this assertion, but I was struck by it. It must have some truth. People living in miserable situations in poorer nations are not necessarily more unhappy, so they must in some sense be tougher. Generations ago, the 'war spirit' (although partly propaganda and nostalgia) seems to have really galvanised some people, so much so that they remember the time fondly for the sense of togetherness. And I think we should expect people to be tough, socially supportive of each other and generally resilient. But simultaneously, we have to offer support where it is wanted or required.
The author also seems to claim that this new policy proposal detracts attention from the social injustices that contribute to mental illness, but I don't believe it's an either/or situation. Clearly we must tackle inequality and isolation with as much vigour as we do their symptoms.
In the end, reading the responses, I found the argument for expanding CBT carried a great weight. I'm no expert on CBT and I've never undergone it, but the evidence base seems to be strong. The proposals for expansion in this area offer on balance many more positive outcomes than might occur without them. And I don't believe at all that they somehow undermine a culture of 'wellness' and 'toughness' that we can all somehow foster. Evidence based psychological therapy, of the kind proposed, is in high demand, and when properly evaluated, is a force for good. We can't afford to ignore that demand and deny it an oppurtunity to work.

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