The Medicalisation of Mental Distress
Many people who experience distress, emotional and mental disturbance, anxiety, and a whole range of unpleasant or difficult experiences end up seeking medical help via the NHS or other healthcare settings. Psychiatry is a branch of medicine that attempts to systematise human distress in clusters of commonly observable and reportable phenomena. As a branch of medicine naturally psychiatry uses the illness model: a paradigm of understanding physical ailments with discreet signs, symptoms, pathology, progression, differential diagnosis and treatment. Unfortunately, emotional and mental distress and disturbance in human beings aren’t very amenable to the same framework of understanding used in clinical medicine to treat physical ailments. This is because ‘mental illness’ is not characterised by the degree of predictability of outcome, progression or causation as physical illness.
Mental Illness is Not Disease
‘Mental illness’ is not disease, in the way that physical illness can be classified in disease terms. However, this has not stopped medicine from attempting to classify human distress in disease terms as it attempts to understand difficult and distressing human experiences and behaviours in a systematised form. The DSM – the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – is a handbook (now in its fifth edition and more closely resembling a major city phonebook) that attempts such systematisation as a reference guide for diagnosing mental distress according commonly observed clusters of ‘symptoms’ or unwanted experiences and behaviours. It can be useful in forming a rudimentary understanding of a patient’s presenting difficulties, naming those difficulties in a way that allows both patient and others in his or her care to share that rudimentary understanding for the sake of reference and with the potential for consistency of care.
Psychiatric Diagnosis Limitations
However, due to the use of the physical illness paradigm in codifying common mental disturbance according to behaviours, thoughts and feelings reported or observed in clinical populations, the DSM and other diagnostic manuals’ cataloguing of human experiences naturally fails to provide in-depth or comprehensive understanding of the individual patient’s lived experience and unique meaning, unique causation and life circumstances, all of which are essential for a true understanding of the patient’s experience. Because human experience – however anomalous it might be with the accepted social norms – is particular lived experience and not disease, it is not conducive to the reductionism involved in ‘mental illness’ classification. Reducing a patient’s experiences to those that seem to fit with a psychiatric diagnosis is only useful in arriving at a conclusion about what label to attach to his or her expression of distress as it has been commonly and statistically observed in others. In my view, this is where Psychiatric diagnoses in general stop being of service to the patient. Because it is human experiences we are referring to, and each individual’s worldview, values, understanding and meaning is a unique expression of that experience, specific ‘treatments’ that might be claimed for individual distresses are, in my view, often a step too far into the application of a medical framework upon non-medical phenomena. Namely, phenomena that might be more appropriately understood in terms of their existential, emotional, social, spiritual and individualistic meanings. ‘Labelling’ and ‘treatments’ in psychiatric terms typically take the form of behavioural restraints, legal and social controls, often for the purposes of individual and public safety, not the amelioration of causes of distress. Pharmaceutical drugs that dull thoughts, subdue anxieties, blunt emotions, restrict extremes of emotion and behaviour, ECT (Electro-Convulsive Therapy), and physical and legal restraints are all forms of temporary containment, not treatment in themselves. Indeed, such forms of treatment often work by causing harm to the patient on some level.
Doctor-centred Understanding versus Patient-centred Understanding
Psychiatric diagnoses are the medical establishment’s framework of understanding brought to the patient’s framework of understanding. It is useful to the degree that it might offer clarity, vocabulary and nomenclature that can be shared between patients and care-givers. However, to impose this framework upon a patient so that his or her individual experience, history of particular causes of distress and particular meaning are obscured or subjugated is where the psychiatric framework loses its usefulness as a tool for helping patients access real help. ‘Therapies’ that simply reinforce the illness model by standardising patient experiences as ‘symptoms’ serve to stigmatise distress even further, obscuring or destroying the inherent meaning within distress itself. Doing so blinds us to the fact that emotional and mental distress are, in fact, human expressions of human suffering, not symptoms to be eliminated by any means. And that as such such suffering has its foundation in real world events for that particular person.
Distress as Human Expression, Not Medical Symptom
With some exceptions, emotional and mental distress are thus often caused by the world, not disease pathogens or toxins in the environment. These causes are typically social and economic in origin: other human beings, economic and social conditions that give rise to suffering either immediately or eventually following their adverse influence. For example: the stresses and strains caused by poverty, relationships, poor parenting, over-work; bullying and other malignant interpersonal behaviours; sexual assault, harassment and abuse, social pressures in dysfunctional work and educational environments upon senstive individuals; traumatic events, warfare, and a whole range of other toxic social, economic and psychological influences acting upon individuals to the point of overwhelm. In such cases ‘symptom management’ as stand-alone ‘treatment’ can be a further insult to the suffering person as the means by which he or she reveals and expresses his or her suffering to the world is silenced or subdued.
For patients, psychiatric diagnoses can offer the beginnings of hope: the promise of recognition of suffering and validation of experience. But many patients also express bitter disappointment at undestanding that never comes; medications that merely curtail clarity of thought and emotion or cause greater difficulties rather than helping; the implied promise of being heard, accepted and cared for that in reality becomes an effort to manipulate thoughts and behaviours in the service of social conformity and to the detriment of personal meaning; the stigma and refusal of access to therapeutic services, to insurance and employment. This, in my view, is because psychiatric medicine and those allied professions who routinely use psychiatric labelling in the service of professional power – some psychologists, psychotherapists, CBT and other therapists, social workers, nurses and doctors – who have aligned themselves with the psychiatric framework have taken the application of this framework too far, applying a paradigm of understanding physical illnesses in the service of pathologising human experiences that is often inappropriate to the emotional, mental, and ultimately existential healing of the suffering person. It is for these reasons that patients and professionals who wish to maintain a more human-centred approach to patient care can usefully approach psychiatric diagnoses with a degree of healthy scepticism and caution; accepting their usefulness as often arbitrary, rudimentary shorthand, but refusing to use a diagnostic category as a restricting lens through which the patient is narrowly viewed, as is often the case. Where such labels are applied in the absence of meaningful, consistent, consensual care and support, they serve merely to stigmatise, serving no greater function than name-calling: legitimate where they assist in highlighting risk, vulnerability or danger. Otherwise, it is crucial that patients who are given psychiatric diagnoses are fully informed about the limitations of such medicalised labelling so that they then retain the power to accept or refuse such labelling where it serves their best interests.
‘Specialness’ and Other Infectious Narratives
So often patients adhere to a psychiatric label simply because of its potential to validate their suffering in others’ eyes. When a patient accepts a psychiatric diagnosis hook, line and sinker, he or she can unwittingly accept the restrictions associated with the psychiatric paradigm and the associated restricting narratives that suggest that ‘only this treatment has been approved or shown to work for this condition’. Some ‘therapies’ and their proponents’ best marketing efforts have merely reinforced the illness model by making often spurious claims about effectiveness for particular conditions that only this or that therapy or specialism can legitimately address. Patients, in their earnest efforts to have their suffering both recognised and alleviated can find themselves in a psychiatric labelling trap: having bound themselves to both diagnosis and marketing hype, reinforcing the marketing narratives that only this or that particular therapy is appropriate for this or that particular diagnosis. Entire industries have been built upon the back of the shaky ground of psychiatric diagnoses and associated narratives about therapeutic efficacy, with vested financial and professional status interests involved in their perpetuation. So often, however, a gift given by one hand can be taken away with the other, and the apparent validation given by a psychiatric label can also come with a flipside of de-validation, disempowerment and deep frustration or torment that can stay with patients for the rest of their lives. This is due in part to unrealistic expectations implicit in the idea that medical-sounding treatments promise a ‘cure’. And in the absence of effective drug treatments, patients unable to access the ‘specialist’ therapy suggested as necessary by social media narratives and marketing campaigns can find themselves banging their heads against walls of institutional indifference when these ‘specialist’ treatments are not offered. In reality, despite the efficacy claims that come and go, there is no convincing evidence to suggest that any one therapeutic model is more effective than any other. Indeed, some claims of efficacy have since been proven to have the reverse effect to what was originally claimed, as in the case of CBT in the treatment of ME/ CFS, Fibromyalgia and other conditions purported to benefit from this approach.
Personal Growth Versus Treatment
The task of the psychotherapist then, is to see psychiatric diagnoses for what they are: basic reference guides for gaining limited insight or understanding. And to help enlighten patients about their psychiatric label’s limits in getting to the heart of personal meaning, and the therapeutic work required for a meaningful recovery out of their suffering and into a place in life where the psychiatric diagnosis can be left behind as a temporary descriptor given for a short period of time that, at best, allowed access to effective help. ‘Special’ therapies typically become yesterday’s snake oil in the therapy world and the most convincing research concerning the effectiveness of psychotherapy is, contrary to marketing claims, not the specific therapy model, but the qualities the practioner is able to bring to the formation of a caring, understanding, accepting, empathic and well boundaried relationship of truthfulness, consistency and respect, rather than the gimmicks of ritual and protocol offered in technique-driven helping models fuelled by vested interests. In this way, human-centred psychotherapists and helpers are in a position to educate and support suffering people through a process of non-stigmatising personal growth on a distinctly human, not medical, journey rather than reinforcing the pathology narrative via psychiatry and treatment branding that a patient must carry for the rest of their lives.
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