Zarathustra had a post recently in defense of the medical model of mental illness. As my background is in the social model of disability, and this is somewhat different from the antipsychiatry movement, I realize that in some respects, the association of the medical model with drugs and biopsychiatry, is correct, especially in the historical context of its emergence in the 1970s. But really, should it be about that?
First of all, science has simply caught up with the idea that there is no biological basis for what we see as mental illness. Even though the biopsychiatric model has probably gone too far a bit, it is well-established that differences in brain wiring and chemistry do exist, and genetic profiling of people diagnosed with mental illness is on the way. For this reason, the construct of mental illness as merely sociological, does not hold true anymore. But does that say anything about the approach we should take to people we think of as mentally ill and the limitations these people face? From a neurodiversity standpoint – and I am aware that neurodiversity hasn’t made it into the general psychiatric community yet, but I hope that will change someday -, I don’t think it does. In fact, the neurodiversity movement, which is an offshoot from the disability movement, says quite the contrary: our neurological differences are ingrained in our brain wiring. In fact, to a number of neurodiversity activists, not including me by the way, this is a major basis for their philosophy of acceptance. To me, however, causation does not change the fact that eveyrone, regardless of mental or neurological difference, has the right to be accepted. Whether you believe in biopsychiatry or in the sociological model of mental illness, or, like me, believe the two cannot be separated, does not change this.
The medical model of mental health may have originated in biopsychiatry and been associated with the view that medication is the primary treatment of mental illness, but that is not what the medical model is from a broader disability rights perspective. (For clarity’s sake: the medical model of course didn’t exist as a concept until the antipsychiatry and disability rights movements came up with their own models.) From a disability rights perspective, the medical model of mental illness views psychiatric disorders as intrinsic flaws in behavior or experience, objectively defined by doctors or other mental health professionals, and in need of fixing through the treatment the mental health professional thinks the patient needs. As you will likely have noticed, I include non-medical professionals here, and the treatment these professionals may use to “fix” someone’s mental illness, may not be biological in nature. Psychotherapists and even social workers can employ the medical model as much as psychiatrists can. The key factor is that they decide who is and isn’t mentally ill, they decide what aspects of the person they decided has a mental illness, need to be “repaired”, and they determine the “fix” they will use on their patients. Usually, lack of regard for external, social circumstances is involved, but not necessarily so: when a mental health professional acknoweldges that a person is in unfortunate circumstances, but they are blaming the person’s lack of appropriate coping strategies on a mental illness, they employ the medical model, too. A slur like “This setting is inappropriate for autistics, but of course we can’t change the setting” employs the medical model no matter how badly the professional uttering it wants to avoid it.
Now that I have made it clear that the medical model is not merely about biopsychiatry, and that many more professionals utilize it than the ones who prescribe drugs for every single complaint a patient comes to them with, what does it take to avoid this model? It takes a shift in philosophy and culture, and that is freaking hard. It requires the viewing of every person, regardless of their mental functioning, as fundamentally acceptable. It requires the view that every individual has the right to make decisions about what happens to their own brain and mind. This, for clarity’s sake, does not mean that a professional should be hanging around doing nothing until the patient has written their own treatment plan. Even if a patient, like me, is pretty much on top of what happens around their own condition, they may not be equipped with all the knowledge they need in order to make a wise decision about their own care, or they may not be able to communicate it. I couldn’t stop cringing in “psychopharmacology 101″, that is, the consultation with my ward psychiatrist I had last Friday to see if medication could help me with my irritability. However, that does not mean that I could just as easily make my own treatment decisions from now on. I emphatically cannot. Communication and cognitive difficulties – reading scientific papers requires different skills than drafting your own real-life treatment plan – aside, I didn’t go to med school. And with regard to psychological treatments, I may have studied psychology for a while, but that doesn’t equip me with the knowledge and skills to make educated decisions about my own treatment per se.
So what do I mean by giving the patient the right to decide what happens to their own brain and mind? It means that, while a professional may provide information and education and quite often actually make a recommendation, the patient is the one who decides what happens to their own brain and mind. Not only that, but a patient should be equipped with the knowledge they need to make that decision wisely, and the skills they need to actually exercise this right. A recommendation for a drug should not be merely motivated by “It will make stuff easier” (one would hope so!) – even though bad puns on drug names along those lines, in the course of a longer explanation, are fine (except that they increase my already high cringe factor tenfold). The same goes for blanket nonsense about the presumed effects of psychotherapy, which is also always presumed to help in the end. Simply saying that the patient is the one who will ultimately decide to swallow a pill (except if they use an intramuscular depot) or come to therapy, is not enough to equip a patient to genuinely assert their right to make their own decisions. This is precisely why a shift in philosophy is required: merely saying that you support a patient’s right to make their own decisions, may too easily lead to blanket statements and concealed coercion.
Here, I presumed that a diagnosis, in fact, can be made without a patient’s input, and it is only about the treatment of that disorder that the patient has the right to make decisions. This is not entirely true. While in the current psychiatric situation, a diagnosis will be made by a clinician, it is increasingly more common for patients to be actively involved in their own diagnostic process. This should not mean that a patient who clearly has, say, schizophrenia, gets to decide that they are depressed because they fancy antidepressants more than antipsychotics. Mental difference is not about fancy, after all. Perhaps more realistically, it also does not mean that anyone with a self-diagnosis of autism, actually has it. Then again, conversely, it does not mean that a clinician can play the psychiatric diagnosis god. Psychiatrists’ and psychologists’ scope of expertise is limited, too, and a key factor in genuinely acknowledging a patient’s right to autonomy, is acknowledging your limitations. If an autistic comes to a psychologist who happens to specialize in, say, personality disorders, it is unethical for that psychologist to diagnose a personality disorder the autistic resembles most, rather than referring them to a psychologist with expertise in autism. It also does not mean that, if that psychologist did not recognize the autistic as an autistic and did diagnose a personality disorder, that diagnosis overrides the autistic’s lived experience. Further, even if a correct diagnosis is made, that does not give the professional the right to ‘splain the patient: while mental diagnoses have value in some respects, they do not override real-life experience. That is, they never override lived experience, even if that experience is thought to be a part of the mental illness. For example, if a person with a psychotic disorder has paranoid delusions and hallucinations, that may mean that no-one is factually persecuting that person, but that does not give anyone else the right to say the patient isn’t really feeling that way.
I need to be making one thing quite clear here, however, which is actually at the core of my belief that the medical model and biopsychiatry are not necessarily interconnected: no-one has the right to ‘splain someone else or to coerce them into making decisions about their own brain or mind. That does mean that the anti-pharma movement cannot dictate that people shouldn’t be taking drugs. Some people may actually think of their mental illness as something biological, or they may have had good experiences with psych drugs. It is up to them to make that decision. That does not mean that you cannot offer them information about the risks of these drugs – and I realize here that not everyone has the access to the book of pharmacological information for physicians I do -, but you should not be giving that information in a coercive manner at all, and that includes refraining from portraying risks as absolutes. Just as much as a doctor cannot prescribe a psych drug with the motivation that “it will make stuff easier”, an anti-pharma activist cannot tell a patient to stop taking their antipsychotic because “it will give you tardive dyskinesia”. In the same way, a psychotherapist cannot constantly tell a patient blanket nonsense about how it will eventually make them feel better, but a therapeutic “freedom” activist cannot tell someone who is having success with therapy, that they should be quitting. It may seem oh so progressively antipsychiatrist to oppose mental health treatment, or psychiatric drugs specifically, but it is as oppressive as the medical model held by mental health professionals if it becomes prescriptive.
One last thing that Zarathustra did highlight, is the fact that, for some patients, too much information can confuse them, and to tell them their diagnosis and how it will be treated, may be the easiest road to travel. Since Zarathustra is a mental health nurse, I am not sure whether this statement reflects genuine lived experience, but I can see how it would. Too much information may actually overwhelm a person and make them unable to make a decision. But then again, is it really up to someone to make that decision for someone else? In fact, I have seen it a few times that a nurse withheld a medication leaflet from a patient because it wouldn’t be “appropriate” for them, even though the patient requested it. It is possible that the leaflet would not carry the most relevant information, for example if the patient takes the drug for off-label use, and it is quite possible that a patient will be freaked out by a side effects profile (I was horrified by the relative risk of cardiac events for the drug my psychiatrist recommended), and it is even possible that the patient’s mental illness symptoms will influence their perception of drug or other treatment information, but is that a reason not to give that information at all? I don’t think it is.
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