Critical Perspectives on the Biomedical Model of Mental Distress – causes or contributory factors
Duration: 10.51 mins
Speakers:
Interviewer, Patricia Caplen
Professor Philip Thomas, Institute of Philosophy, Diversity and Mental Health, University of Central Lancashire, UK.
My name is Pat Caplen and I’m a carer for my husband who has multiple physical and mental health problems, and I would like to introduce you to Phil Thomas.
Thank you very much, Pat.
Thank you. From your perspective, what do you see as causing or contributing to mental distress?
I think I’m going to have to answer that question in a rather roundabout way by first of just describing to you how psychiatry, how a medical model in psychiatry interprets and understands distress. Psychiatry makes the assumption that the various forms of distress that people experience, whether it's depression, hearing voices or having strange or unusual beliefs, arise because of disturbances in brain function. Now there’s a long history in psychiatry for this; it goes back at least 150 years, probably till the middle of the 19th Century, and at the end of the 19th Century the ideas were sown in German psychiatry that resulted in the major categories of mental illness that we have today and that we recognise – conditions like schizophrenia for example or severe forms of depressive, affective disorder. In the large asylums at the end of the 19th Century there were many, many different types of people brought together under those roofs. Some of them had conditions like neurosyphilis, pellagra, vitamin deficiencies, epilepsy – a wide range of very serious physical problems – together with people who today would be recognised as suffering from conditions like schizophrenia. Now of course as the health of the population as a whole has improved over the last 100 years, those sort of physical forms of insanity or madness are now much less common; we hardly ever see them at all, largely because of advances in medicine. But what’s happened is that we are still left with these conditions – schizophrenia, manic depression, those sorts of disorders as they’re seen – and what happened in the asylums of the late 19th Century was that the early psychiatrists believed that conditions like schizophrenia would turn out to have physical causes, like neurosyphilis, vitamin deficiencies, epilepsy and throughout the 20th Century what we’ve seen is a repeated history of investigations into attempts to find the underlying physical basis of conditions. Let’s take schizophrenia as an example because it’s probably the best known one. I remember when I first started training in psychiatry in the mid-1970s that the dopamine theory of schizophrenia had just come into popularity. I think the work that was, the seminal papers on that were published in the early 1970s, and that replaced a whole series of earlier theories about schizophrenia which were no longer thought to be true or important. People were interested in pink spots in people’s urine and things like that. Now over the years, and especially as new forms of technology have grown, psychiatrists and researchers have subjected the brain to examination in any number of different ways, in an attempt to find this elusive abnormality in the brain of people who suffer from schizophrenia. But again, the history over the last 30 or 40 years has been that yes, we’ve found out that, let’s say there are these abnormalities in these receptors but actually when you take into account the fact that people have been treated with neuroleptic medication, you find that those abnormalities were related to the treatment or they were related to institutionalisation or they were related to other aspects of the care that people receive for schizophrenia. So what I’m going on to say is that where we are at the moment at the beginning of the 21st Century, sort of 150 years on into this exploration of the causes of conditions like schizophrenia, is to be frank, we’re not any further on than we were 150 years ago. And I mean people will say ‘well, Phil Thomas will say that anyway because he’s a critical psychiatrist’. I would simply refer you to things that prominent American psychiatrists, most notably Professor Nancy Andreasen in the University of Iowa, who is a leading authority on neuroscientific research. In a number of interviews and articles that she’s published lately towards the end of her career, she’s admitted that really we’re no further on in terms of understanding the causes of madness. If you like the 1990s were called the ‘decade of the brain’ in America. George Bush Senior announced in 1991 that there was going to be a huge investment of resource, of research and money into trying to find the causes of schizophrenia and Nancy Andreasen was very much a part of that process in American psychiatry. She wrote and published a book in the mid-1990s called ‘The Broken Brain’, but sort of 15 years on from that now, people like Nancy Andreasen and other prominent American psychiatrists who have been right at the heart of this sort of search for the biological basis of psychosis, are actually turning around now and saying ‘well to be honest, we’re not really any further on’. So that leaves the question, how are we to understand these conditions? This is where I would say that my position is really very different from, let’s say, the anti-psychiatrists in the 1960s – Thomas Szasz for example famously declared that the idea of mental illness was a myth, that there was no such thing as mental illness, and that’s plainly to me absurd because people suffer, families suffer, individuals suffer enormously from the experiences associated with madness and psychosis. So I think really we have to turn to other ways of trying to understand what the experience of psychosis is, what might bring it about, what causes it and how we might understand and respond to it. I suppose there are some useful ways of beginning to think about that now that we’re beginning to change the way we think about it, but epidemiologists for example – epidemiologists are scientists who study the patterns of diseases in large numbers of people, in populations and across countries and across cultures. There’s been a lot of epidemiological research over the last 15 to 20 years that shows quite interestingly that if you actually go out into the community and ask lots and lots of people on the street, let’s say, whether or not they’ve ever had an experience like hearing voices or whether or not they’ve ever had strange or unusual beliefs, that around 10-15% of people will actually say ‘yes, I’ve had the experience of hearing voices’. Now that’s far higher than the number of people who would ever actually present to psychiatrists and have a diagnosis of schizophrenia. And furthermore, when you actually study these people, as has been done both in London, in America and in one or two other places recently, when you actually subject them to interviews and you actually examine in detail the nature of their experiences and the effects that these experiences have on people’s lives, they’re every bit as, they’re almost, they are identical to the sorts of experiences that people would have if they were seeing a psychiatrist and had a diagnosis of schizophrenia. So I think the point about this is that I think we’re moving away from the idea now where we think of psychosis as being something that’s related solely to a small number of people who have a diagnosis of schizophrenia and we see the propensity or the extent to which an individual is likely to have an experience like hearing voices or strange beliefs, as distributed throughout the whole population. In other words, experiences like voices or strange or unusual beliefs exist on a continuum, that there’s no difference between people in the community who have these experiences and people who get to see psychiatrists. The only – and this is really important – the only major difference between people in the community who hear voices, let’s say, and those who are psychiatric patients, is that psychiatric patients find it much more difficult to cope with their experiences and are either much more distressed by their experiences or alternatively they cause people concern because they have them.
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