ABSTRACT
At present Alice is much more likely to be given only antidepressants. It is a matter of luck whether her GP will know of a help line, whether s/he will even consider the usefulness of such an alternative, or whether the health visitor will raise this possibility with her and her GP. A paradigm shift in the context of mental health is in existence when we begin to doubt whether the usefulness of the existing hegemonic paradigm is over taken by its un-usefulness – either/or conceptually, methodologically, ethically, and in everyday intervention. The harm seems to outweigh the benefit attributed to such an approach; when central planks of the issues at stake are not taken into account – or denied attention – by that hegemonic paradigm according to major stakeholders; the beginning of an alternative perspective is delineated. We would be arguing in this book that indeed we have reached this state of doubt concerning the hegemonic model of mental health, namely the ‘medical’ model, or more correctly the biochemical model of mental illness. The issues denied prominence and due attention form a long list, including themes such as: • The social context and its variables • Health as distinct from the absence of illness • The psychological layer as an etiological factor, including the impact of abuse • Power relationships and their impact within the mental health system and in its
wider social context • Recovery as a realistic option for people with psychosis. The continuous invention of new types of medication, some with fewer side effects than the previous generation and hence more effective in suppressing symptoms and enabling people to lead a more ordinary life, is presented as the proof that the biochemical model is working well and should not be discarded. No one would wish to deny relief to people who suffer relief from pain. Yet it needs to be asked at what cost to them – and to the rest of us – is this relief obtained. Is it long lasting? Have the alternatives been given a fair trial? If Alice would take the medication prescribed would she be able to stop taking it at the end of the period prescribed by her doctor, or would she become dependent on it? Why, despite these achievements, more and more people – lay and professionals alike – are raising their doubts as to the validity and effectiveness of the medical model (Rogers, Pilgrim and Lacey, 1993; Ramon, 2003)? In typical relationships between doctors and patients or nurses and patients, the latter are often grateful for the professional intervention offered by the first. Yet fewer of those using mental health services express such gratitude. When asked, users would indicate that they have met good and bad practitioners; highlighting that the difference between the two is not about their professional ability but whether they treated the user as a person, whether they felt respected, cared for and attended to as a human being. This response, especially expressed in the context of in-patient facilities, reflects some of the key differences between medicine and psychiatry. Users of mental health services can easily be seen as needy of, or greedy for, attention, due to being in turmoil, feeling a failure and being rejected
by others, especially when in crisis. They therefore seek to be compensated for the above in the contact with professionals, but often feel rebuffed. While some of the difficulties in the relationships are related to lack of enough workers able to provide good enough attention, it is also true that medicine – of which psychiatry is a branch – trains professionals who focus on the part that needs to be cured, while being polite and courteous. Being polite and courteous is insufficient in terms of the type of attention the sufferer from mental distress or illness wishes for and requires. This way of relating to people implies that professionalism is not about a distanced, ‘hands off’ approach, but instead requires emotional closeness, a ‘hands on’ approach, and the demonstration of interest in those everyday affairs which matter to the service user. Alice felt truly relived when the health visitor asked her to tell her in detail about getting up in the morning and preparing the children for the new day, and even seemed genuinely interested in what she had to tell. It was the first time that a professional showed an interest in what she found particularly difficult, but could not bring herself to discuss as it was ‘so trivial’, and she was sure none of the professionals would be interested. Providing satisfactory care in mental health is a mentally and psychologically demanding activity, one which requires considerable time, continuity and hence a sufficient number of sufficiently qualified people to carry it through adequately. The ‘hands on’ approach which enables the client to get on with her/his life, the shortening of the distance between professionals and users, and the demonstrable emotional availability of the worker is what marks good psychosocial professionalism from the traditional model of practising psychiatry. Although low in technological costs, mental health services are bound to be financially expensive because they are labour intensive, and will need to be largely met through public sector funding. Nevertheless, there are significant differences as to the cost of different forms of interventions and policies, with hospital care being the more costly setting. The critique of the medical model in the context of mental health has focused on its denial of the existence of the impact of the social context in leading to mental distress, in interacting with any biological or psychological intervention, and therefore in impacting on recovery too. This critique is not new; its hay day dating back to the 1960-1980s. The core of that critique has been since accepted as valid, yet most of it has been neatly ignored by the protagonists of the medical model and those circles impacted by them. This attests to the power of the medical model within and outside the mental health system, and the relative lack of power of the protagonists of the critique. It also reflects the degree of discomfort this critique causes to those who are in the position of acting upon it. For example, we are witnessing now the introduction of mental health teams to primary care, staffed by nurses with skills in brief psychological interventions, for which there is a convincing evidence base of the likely benefit to the many people approaching primary care presenting the first signs of depression and other types of minor mental illnesses (Armstrong, 1995). Likewise early psychosocial intervention in psychosis is proving to be a valuable intervention (Jackson and Farmer, 1998, and chapter 11 by Jones and Gamble in this text), as are attempts to work within a psycho-educational model with families (Falloon and Fadden, 1992).
This new way of working reflects the recognition of the value of psychological interventions, as distinct from – though not in opposition to – the medical model. It attests to the acceptance that medication for these types of difficulties is, at best, of limited value because it does not enable the person to develop better problem solving and coping strategies, but instead fosters a denial of the implications of the symptoms and their meaning in the person’s context. Yet the same approach to mental health in primary care is taken regardless of whether the practice is based in a run down or a posh area; ignoring the level of poverty, isolation, and socio-economic deprivation to be found in a poor area to which clients return from the brief intervention. A new national initiative regarding the reduction of domestic violence, because of its damage to the mental health of women and children, started in 2002, yet the connection between domestic violence, minor and major mental illness was not made and the most recent interventions for the latter are not informed by the former.
