Re-defining Mental Illness

Valmont · 22-01-2015 8:40am #1

The NY Times is running an interesting article on the shift away from the biomedical approach in psychiatry and psychology. I do wonder though, given the century of evidence that people are now recognising that mental illnesses are wholly unlike physical illnesses, why persist in calling them 'illnesses' at all?
http://www.nytimes.com/2015/01/18/opinion/sunday/t-m-luhrmann-redefining-mental-illness.html?_r=0

JuliusCaesar · 23-01-2015 1:02am

Well, I guess it's a step on from moral failings and being possessed by demons. Now we have to get to the biopsychosocial and start looking more at systems, environments as well as individuals. The impact of meaning, purpose, community. We are a social species after all.

Valmont · 23-01-2015 8:13pm

I agree that a biopsychosocial perspective is a more meaningful therapeutic tool, but as a scientific model of human behaviour it stinks. And given the consensus on the biomedical model we don't have a very positive outlook for the scientific status of psychology (I would argue it's always been shady in certain respects) along the lines of the physical sciences.

JuliusCaesar · 24-01-2015 11:08am

I am a pragmatist. I need to be; I WORK with people with mental disorders all the time. I could say that the biopsychosocial approach is theoretically flawed and refuse to use it; I could stop working with people and sit in my office and cry that we don't have a sufficient theory of mind. Or I could do the best I can with people, given the state of knowledge that we have at present.

From wikipaedia:

However, a vocal philosophical critic of the BPS model, psychiatrist Niall McLaren,[27] writes:

"Since the collapse of the 19th century models (psychoanalysis, biologism and behaviourism), psychiatrists have been in search of a model that integrates the psyche and the soma. So keen has been their search that they embraced the so-called 'biopsychosocial model' without ever bothering to check its details. If, at any time over the last three decades, they had done so, they would have found it had none. This would have forced them into the embarrassing position of having to acknowledge that modern psychiatry is operating in a theoretical vacuum."[28]

The rationale for this theoretical vacuum is outlined in his 1998 paper[29] and more recently in his books, most notably Humanizing Psychiatrists.[30] Simply put, the purpose of a scientific model is to see if a scientific theory works and to actualize its logical consequences. In this sense, models are real and their material consequences can be measured, whereas theories are ideas and can no more be measured than daydreams. Model-building separates theories with a future from those that always remain dreams. An example of a true scientific model is longer necked giraffes reach more food, survive at higher rates, and pass on this longer neck trait to their progeny. This is a model (natural selection) of the theory of evolution. Therefore, from an epistemological stance there can be no model of mental disorder without first establishing a theory of the mind. Dr. McLaren does not say that the biopsychosocial model is devoid of merit, just that it does not fit the definition of a scientific model (or theory) and does not "reveal anything that would not be known (implicitly, if not explicitly) to any practitioner of reasonable sensitivity." He states that the biopsychosocial model should be seen in a historical context as bucking against the trend of biological reductionism, which was (and still is) overtaking psychiatry. Engel "has done a very great service to orthodox psychiatry in that he legitimised the concept of talking to people as people." In short, even though it is correct to say that sociology, psychology, and biology are factors in mental illness, simply stating this obvious fact does not make it a model in the scientific sense of the word.

The separation of psyche and soma is endemic in our SYSTEMS of health (we have mental health, and general health), and in the popular mind. The BPS model may well consist of those 3 words, but does serve the purpose of reminding people that there are those three major aspects of people that need to be taken into account when working with them.

Valmont · 25-01-2015 4:14pm

Like I said, it has definite therapeutic benefits but it casts a huge epistemological shadow over psychology being in the science sub-forum on boards. The practice of psychology, based as it is on a catch-all term like 'biopsychosocial', is not scientific in any meaningful sense. The only science involved is whether a particular therapy works or not, whereas how or why it might work cannot be answered. This is a serious problem for the field ever hoping to actually understand the mind and human behaviour.

Clinical psychologists like giving advice on how people should live their lives and often invoke 'science' as being behind their pronouncements when in reality the science behind their psychology is no more advanced than the star signs in the local paper. I think from an ethical point of view this pretence is dishonest and misleading for the people who avail of the services provided by clinical psychologists.

So you don't have to cry or give up, but perhaps stop pretending you're a practising scientist! I don't think this a bad thing either, psychologists can still help people without pretending they actually solved the juncture between the mind, brain, and environment.

JuliusCaesar · 25-01-2015 11:11pm

Ok, I put my hands up, I'm an alchemist!

(But I don't give advice to people about how to live their lives. I wouldn't be so arrogant. I am a humble pragmatist. Also, I do look for evidence, such as it is, because it's better than the alternative - and heavens there are a hell of a lot of charlatans out there. Some are even qualified clinical psychologists, or psychiatrists. But most of us are doing what we can, with the knowledge we do have, and the state of evidence at the moment. Have you any idea how young psychology is compared to the hard sciences? Should we just give up because of that?)

Valmont · 26-01-2015 12:40pm

I think you misunderstand my position. I don't think clinical psychology is doomed or irrelevant in any way. However, as for giving up, I think accepting the biopsychosocial 'model' is giving up; the more professionals and researchers carry on with the charade that this is our grand underlying theory of why people behave, think, and feel the way they do, and that it is acceptable then there is much less of an impetus to develop new and better theories. I would argue that there is ample evidence in all fields of psychology to drop the 'bio' but a slavish loyalty to the outdated methods of psychiatry keep us using it.

When people want to learn about the best way to understand why they or a loved one is behaving in a distressing manner they are often told by psychologists (and I have now seen this in practice in a hospital) that the best way to think about these things is from the 'biopsychosocial' perspective thinking that this actually explains anything. It's like saying someone is depressed because of 'universal forces' - technically true but vacuous in the extreme. The one area where psychology is scientific is in the effectiveness of certain treatments, you can't argue with the evidence that something works from a pragmatic point of view. However, if there is any grand progress to be made, we have to be a bit more enquiring as to why it works. Usually, that means ignoring fruitless physiological theories and drifting back into philosophy, which unfortunately is politically unpalatable for many practitioners and academics. CBT, the most effective 'treatment' for many personal problems people have is based hugely on the writing of the Stoics. I think if the Stoics were able to arrive at CBT three millenia ago without SPSS then perhaps the search for an answer could expand beyond the limited scope of null-hypothesis testing. Perhaps this could take the form of a more Socratic and deductive analysis of the mind, I don't know really, but I do know the lack of any real will to explore further by psychologists is worrying.

JuliusCaesar · 26-01-2015 8:21pm

Psychology is researching everything in any number of directions.

We are a very young science.

If people are using the 'biopsychosocial model' in the way you say without any mental reservations, then they are unthinking; but we often in the real world use terms which are shortcuts or heuristics for what we really intend/mean. It is often better to use the diagnosis or BPS or whatever in terms of simplifying communication within the MDT. We can't be arguing every blinkin' point all the blinkin' time without severe damage to MDT working, and without severe impediment to getting the actual work done.

PS I believe Ayurvedic medicine, and acupuncture also have a long long history....

Re-defining Mental Illness

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