Luuk L. Westerhof, Master’s in health Promotion: Certified Clinical Family Therapist: Certified Social Worker: Certified master Instructor: Certified Drug and Alcohol Interventionist: Certified Supervisor. For contact, kontakt@sponte.no
Abstract
There is a high prevalence of diagnostic application in psychiatry something that regularly provokes strong reactions. Psychiatry may appear less contextual and thus less humane. The use of diagnosis has developed and has become more pervasive in recent years. How should this development be understood in light of the diagnosis's validity crisis and lack of contextuality? The current development probably does not have a scientific sustainability and is in this article considered as a consequence of a less plural and more decontextualized psychiatry.
Keywords
Medical Psychiatry: Culture: Context.
Mental illness or mental problem?
The term 'mental problem' is used in this article, not 'mental disorder.' The latter may insinuate that the individual is the bearer of an essence, an inherent state of deficiency. The essence exists independently of the observer and subjective interpretation. This is too narrow and uniform an explanation for such a complex phenomenon as mental illness. The term mental problem is more comprehensive to describe mental challenges not only as an intrapsychic process, but also as culturally, contextually, and socially constructed. Mental problems are understood by the author as co-constructions that have emerged within cultural and social contexts. Mental problems thus do not exist independently of the observer's subjective interpretation and can thus not immediately be classified as a disorder or as essentialism. When the individual is struggling with mental problems, it is not at all certain that there is something wrong with him or her, on the contrary, there may be something wrong with the cultures and contexts the client is a part of.
How can a mental problem be understood?
A mental problem can be understood from different perspectives: Essentialism, socially constructed phenomena, pragmatic classification, and commonalities of underlying mental mechanisms (K.S Kendler, Zachar, & Craver, 2011). The first two perspectives are relevant in the context of the article and briefly mention something about these.
Essentialism
The essentialist model of understanding psychiatric problems deals with the fact that the problem itself (the symptom) has essences, they exist regardless of the observer's classification of them. Essentialism thus postulates that the person is the bearer of the problem (essence). A mental problem is considered an inherent deficiency condition which, like a machine, can be fixed by a knowledgeable expert. If a mental problem is to have an essence, the causal relationship of the symptoms must be clearly connected with the underlying clear and definable causes, just as in somatics.
The essentialist understanding of mental illness is unsuitable for understanding and explaining mental problems (Hagen & Kennair, 2020; Aarre, 2018a). When an individual struggles "… because of…" it is not at all certain that there is something wrong with the individual, the problem may also lie in the contexts the individual is a part of. The causal mechanisms of many mental problems and disorders, such as social phobia or personality disorder, are enormously complicated and can thus not be attributed to a simple essence as a cause (Hagen & Kennair, 2020).
Social constructionism
Mental problems can be considered as socially constructed phenomena. In my view, this is a more humane and contextual approach. The postmodern social constructionist approach is based on the idea that mental problems arise in the wake of a culture's categorization of them (Burr, 2015; Gergen, 1969, 2000, 2001).
The problems thus do not exist independently of subjective perception (Maturana & Varela, 1998) on the contrary, they are co-created by the perception itself and concept-setting.
From a social constructionist perspective, mental problems and their categorization through cultural and social glasses are considered to which we can attribute certain traits, meaning and characteristics (Wakefield, 1999). For example, internet addiction, gambling addiction and sex addiction are new and newly constructed diagnoses (Hagen & Kennair, 2020, p. 14). The Freudian diagnosis of hysteria in women, on the other hand, has disappeared as a diagnosis and construction.
The client knows best where it hurts most
In recent years, a greater global skepticism has developed towards the biomedical approach in psychiatry (R. Whitaker & Cosgrove, 2015). My ambivalence is based on some of my own experiences as a professional in substance abuse care and psychiatry. The biomedical approach is based on the premise that the causes of the client's mental problems lie as an essence in the client in the form of disturbed biological, psychological, or behavioral functions (Aarre, 2018a, pp. 22-23).
In an article in the Journal of the American Medical Association; "Psychiatry as a Clinical Neuroscience Discipline" (2005) director of the National Institute of Mental Health, Thomas Insel writes that mental disorders are complex and genetic disorders where aberrant chemistry and network disorders in the brain lead to behavioral symptoms (Insel & Quirion, 2005)
Some of my experiences from substance abuse care and psychiatry have led me to believe that Thomas Insed's biomedical approach alone is insufficient in being able to understand and help clients adequately with their complex mental health problems. There was a time when I really thought that psychiatry could help people get better. Today I have lost much of this faith. I have become more convinced that we need to listen more to what the client has to say about his life and mental problems. What does the client think about what he or she needs to get better? What thoughts does he or she have about his or her own treatment and medicalization? It is the client himself who knows where the shoe hits the most. Taking a more client-centered perspective is more compatible with the idea that the client himself is the best manual for self-improvement (Hertz, 2008b).
This does not mean the same as that psychiatric competence is superfluous in treatment. But it could raise the quality of psychiatric aid if it facilitates for changes in how to respectfully meet people. I believe this is necessary for psychiatry to appear more credible and meet the expectations clients have of them (Aarre, 2018a).
Clients today no longer settle for expert opinions, incomprehensible diagnoses, and expert solutions that they cannot agree with. In our enlightened and digital everyday life, the client is more enlightened than ever before and asks legitimate and good questions about what concerns their problems and process. The client rightly doubts the many professional assessments that deal with their treatment. Most clients no longer slavishly follow so-called evidence-based treatment methods. They will be listened to, and they will be an active co-determinant in decision-making processes related to their treatment. Will such an approach appear as a more humane and contextually oriented psychiatry (Aarre, 2018a)?
As a natural consequence of a greater body of knowledge about their own problems, the client also challenges the very foundation of the psychiatric field, including diagnoses, classifications, and treatment options. Psychiatry works according to the book and adheres to evidence-based approaches. The question is whether this is sufficient to remedy the client with his mental problems. One might think that this is the case, but it is a paradox that clients come again and again for more help, just as it was for Johann Hari (see below). From time to time, people get good help, and we must not forget that. But I continue to be skeptical of the biomedical approach to mental health problems, especially because it lacks validity and because it does not take sufficient account of the contextual.
Is the application of the biomedical approach problematic in explaining mental health problems?
In 2019, Bloomsbury Publishing published a book by the English science journalist, Johann Hari. The book became a bestseller: "Lost Connections - Uncovering the real causes of depression and anxiety" (Hari, 2019b). Johann Hari studied at the prestigious University of Cambridge in Great Britain. For much of his life, Hari experienced depression and described these feelings as pain that flowed out of him. He decided to seek professional help.
In the first consultation with the doctor, it took no more than 6 minutes before Hari had been diagnosed. Hari was told why he was depressed and that there was a chemical imbalance in his brain (lack of serotonin). Hari was told that he needed medication in order to get rid of his mental ailments. The doctor ordered Paxil (antidepressants) in moderate doses. In the initial phase, the medication was of great help and Hari became convinced that he had found the remedy for his mental problems. But, unfortunately, eventually the symptoms returned, and Hari went to the doctor again for more help. The help he received was an increase in the dosage of Paxil. For a while it was helpful, but the symptoms returned in full force and the doses increased in proportion to the years. In total, Hari spent 13 years on Paxil but did not get better.
Hari says in a TED-Talk (https://www.youtube.com/watch?v=MB5IX-np5fE) that he was never asked "why" he felt depressed, even though he was treated according to the book. Hari's treatment was based on a diagnosis where questions about culture and context are less relevant, and where the questions asked are more about how the deficiency condition can be explained, medically. In other words, it is not so important why you are depressed more important how it can be explained. With that, the biomedical explanatory model appears, to me, as an oversimplification of complicated mental problems that should be seen more in the light of culture and contexts of social disorder (Hertz, 2008b; Moncrieff, 2008) and culture: We are each other's context (Anderson, 2007; 2013) and mental phenomena most often occur within the social community.
Such a perspective opens for a continuum approach where psychiatric problems vary in strength, from context to context, from culture to culture. A human being may have genetic vulnerabilities (genotype), but they are expressed (phenotype) and activated in interaction with the environment (Tor-Johan Ekeland, lecture at the House of Literature in Oslo 21 March 2019). As I understand Ekeland, he talks about the cultures and contexts that contribute to the development and expression of mental problems.
Serotonin deficiency or too much dopamine in the brain is cited as a causal factor in mental health problems. The problem with this theory is that none of these values are measured, stronger, they cannot be measured (Peter Roger Breggin, 1983; Peter R. Breggin, 1993; Peter Roger Breggin, 2008; Peter Roger Breggin & Cohen, 1999; Kinderman, 2014aa,2014b). It's more about a story about why the client suffers. The one who benefits from this theory is the pharmaceutical industry (B. Whitaker, 2002; Robert Whitaker, 2010a; R. Whitaker & Cosgrove, 2015). For the client, the explanation is of little use. More appropriate is to arouse a curiosity about what the client may have been affected by in his life.
The Norwegian professor Anna Luise Kirkengen wrote the book «How abusive children become sick adults» (Kirkengen, 2009). She documents a link between violations (trauma) in childhood and reduced quality of life in adulthood. The question should probably not be what is wrong with the client, but rather, what wrong has affected the client's life and what implications the client experiences even these events have on his or her mental health.
Vincent Felitti and Robert Anda conducted a longitudinal study with over 17,000 participants (Robert F. Anda et al.; Dube, Anda, Felitti, Edwards, & Croft, 2002; Felitti et al., 1998) at the CDC (Burns, United States. Office on Smoking and Health., & Center for Disease Control.) - Kaiser Permanente. The ACE study (Adverse Childhood Experiences) is one of the largest completed research projects that deal with neglect in childhood and what implications they may have in adulthood on health and experience of well-being and behavior. Over 17,000 members of the "Health Organization" from Southern California underwent physical examinations in addition to a confidential survey of the individual's childhood experiences and current state of health, experience of well-being and behavior. What Felitti and Anda were curious about was whether eating disorders could have a coherence with childhood trauma. Findings confirmed that childhood trauma can to a large extent be linked to mental problems and obesity in adulthood and a lack of experience of well-being. These findings document that mental problems should not be understood detached from the client's life history.
How has the client fared so far?
A few years ago, I was at a meeting in a psychiatric ward. 13 professionals from different disciplines were present. The meeting was about a client who had a relapse (recurrence) intoxication and had become acutely psychotic. The client had managed for 6 years without drugs, had gotten a permanent job, owned an apartment and had a well-functioning social network. After 6 years without drugs, an event occurred in her life that changed everything. The incident was so traumatic that she could not talk about it. She had a relapse and also became psychotic and lost almost everything she had managed to build up. At the meeting, it was decided that she should be forcibly admitted. At the meeting, I heard about everything that was wrong with the client, what diagnosis she had and how she was being medicated. What I unfortunately did not hear anything about was a curiosity about how this woman had managed in all those years without drugs. Unfortunately, no one cared about what had affected her life through no fault of her own. I probably became unfriendly with most people when I said:
"I'm surprised that none of you show a curiosity about how the client has fared in all those years without drugs and medication. How did she manage to use her resources to live a drug-free life? How did she manage to mobilize her creativity and energy so that she could live a good and productive and social life? And what may have affected her life that has contributed to this relapse? "
In psychiatry, a greater interest in the client's life history and cultural affiliation should probably be developed so that one can meet and provide help more adequately. We can help the client even better if we get an eye on how and why the mental strain arose. It can help to design more targeted treatment. What have I become curious about is what made us believe that mental problems are detached from culture and context? What made us believe that mental health problems are only related to disrupted biochemical processes in the brain?
I believe that psychiatry has embraced the biomedical explanatory model because it is based on thoughts about the presence of symptoms as evidence of mental illness. The diagnosis is confirmed by the symptoms which by definition are an indicator of mental illness and disorders. A reverse reasoning is that mental disorders must be there because of the symptoms that are accepted as the primary problem.
Johannes Hari had symptoms of anxiety, depression, and suicidal thoughts. These symptoms were not his primary problem, they were probably more manifestations of underlying disorders (Romer et al., 2018). The biomedical explanatory model interpreted his depression as confirmation of a disturbed chemical balance in neurology. A more appropriate approach is to develop a curiosity about why Johannes Hari felt depressed, sad, tired, struggling and at times suicidal? Hari himself says that some of the underlying factors were that he was abandoned by his girlfriend and that he was without steady meaningful work. Allen Frances (Frances, 2013, p. XVII) says something of the same:
As I drifted around the party, I met many other friends working on DSM-5 who were similarly excited by their pet innovations and soon discovered that I personally qualified for many of the new disorders that were being suggested by them for inclusion for DSM-5. My gorging on the delectable shrimp and ribs was DSM-5 “binge eating disorder.” My forgetting names and faces would be covered by DSM-5 “minor neurocognitive disorder.” My worries and sadness were going to be “mixed anxiety/depressive disorder.” The grief that I felt when my wife died was “major depressive disorder.” My well-known hyperactivity and distractibility were clean signs of “adult attention deficit disorder.” An hour of aimable chatting with old friends, and I had already acquired five new DSM diagnosis. And let us not forget my six-year-old identical twin grandsons-their temper tantrums were no longer just annoying; they had “temper dysregulation disorder.”
We must be aware that psychiatry does not become a self-recruiting system, where ordinary people with normal mental challenges are made sick. If we were to keep the biomedical explanatory model correct, the threshold for diagnosing phenomena such as mental problems should be high so that it can be established that many of the client's responses are about healthy reactions to unusual events in life. Unfortunately, with each new edition of the diagnostic manual, the threshold has been lowered. This applies to both DSM-V (Diagnostic and Statistical Manual of Mental Disorder) (First, Frances, & Pincus, 1995) and ICD-10 (International classification of diseases). One of the biggest challenges with today's diagnostics is the separation between normality and disorders. How to define normality when the majority of the population is ill?
Mental problems are real
Mental problems are real, they are often painful and can interfere with normal functioning. There is a big difference between dysfunctions and legitimate responses to abnormal conditions. This is not philosophy. Johann Hari took antidepressants for 13 years because he was depressed. As I said, the biomedical understanding model is ill-suited to explaining mental problems. Mental problems arise in contexts of social disorder and cultural contradictions and challenges (Hari, 2019b; Hertz, 2008a; Aarre, 2018b).
A biomedical approach in psychological help work is of little use precisely because it is not supported by facts (B. Whitaker, 2002; Robert Whitaker, 2010a). Professionals do not quite know why people experience mental disorders and mental health problems. Could it be that mental problems are not located in the genes or biochemical deficiency conditions? Maybe mental problems are not even about what is up in the head or brain, but that it is more about what happens around an individual and how it affects mental health and the experience of well-being. In this context, we may wonder what implications traumatic events have on the client? No one has ever been able to prove that what we call mental health problems are caused by individual dysfunction, chemical imbalance, or illness. In that case, these have been useless. The result has been that a belief has developed that the client is really ill or disturbed. I'm very unsure if this is the case. To keep all perspectives open, we should refrain from asking what is wrong with the client and rather be curious about what is wrong that has affected the client's life. What does the client think about how he or she can best be helped? What does the client think about their problems? Where does the client experience the shoe pressing the most?
A response to the diagnostic and contextless psychiatry lies in a more plural approach and greater willingness to listen more to the client. It is the client who is the primary source of information for the information needed to be able to offer adequate and tailored treatment. This can be understood as an “not-knowing-position” (Anderson, Gehart, & Anderson, 2007). An attitude that does not postulate knowing anything, but a position that indicates that we cannot know anything about the client unless the client tells us so himself.
Such an attitude requires humility, the ability to listen and take the client's subjectivity seriously. There should be a greater openness and willingness to doubt what is read in textbooks as absolute truth, and shift to a greater responsiveness to the client's reflections on what is best for him or her. What is written in textbooks is by definition not wrong, but theory is only as useful as it helps the client.
Are we more Roman than the Pope?
In psychiatry, there is a tendency to talk about the client as if he or she is so very different from ourselves. In reality, there are greater similarities than differences. It is not only the client who may struggle with mental health problems. Professionals also experience such challenges, and no one is more Roman than the Pope!
When I started to hold large gatherings, I was nervous and scared. I had many ideas about what could go wrong. This was probably not a sign of biochemical disorders or mental illness. It was probably more about normal symptom expressions of challenges that were outside my comfort zone.
I have experienced depression and sometimes wished myself away from this world, but have never thought of it as a disorder, or mental illness. I have understood these phenomena in the light of the contextual: how do I experience myself as a citizen in this world in relation to (...?) Can I still attribute meaning to my existence?
Many people feel this way, somehow something unexpected, unforeseen, or traumatic happens in their life. Something is destroyed and disturbed. People's reactions to such unexpected events should then not be linked to a mental deficiency state, but rather interpreted in light of healthy reactions to challenging demands and events. A more contextual and humane psychiatry is, among other things, about not making normal reactions to abnormal events and challenges in life sick.
Why do we need a different approach?
The biomedical understanding model may seem attractive. It tells the client that what he or she is struggling with can be corrected and perhaps cured through medical intervention. Why do we really need something else? The biomedical approach itself is not wrong, but in line with psychiatrist Trond F. Aarre, I believe that it does not fulfill its promises (Aarre, 2018a).
A pragmatist will argue that a workable approach can be useful even if it turns out to be wrong. A pragmatist will probably not find anything that satisfies him in terms of the biomedical model. First, the current diagnostic system is not valid (Frances, 2013; Robert Whitaker, 2010b; R. Whitaker & Cosgrove, 2015). The aim of the diagnostic system is to get a prognosis and a systematized treatment in place, but the diagnoses are not very well suited for this either. And mental disorders are not real entities in this world as independent of our observation and interpretation (Frances, 2013; Robert Whitaker, 2010b; R. Whitaker & Cosgrove, 2015).
Homosexuality is a good example of how a phenomenon can be understood based on culture and context. Homosexuality was originally a conceptualization of a phenomenon that was considered a mental disorder; "ego-dystonic homosexuality". But, as we know today, the diagnosis has not stood the test of time. Why not? One way to understand this is that culture and context are dynamic and thus also the phenomena that arise in them. Diagnoses are nothing more than a systematic categorization (taxonomy) of symptoms that are labeled as abnormalities, deficiency, or pathology. Changes in cultural and contextual conditions lead to changes in symptom and pain expression and propagate in the contexts of which the client is a part. This is a systemic perspective which takes the focus away from the individual as ill, and rather draws attention to the contexts with which the individual interacts. Another example is "gambling" which has been described as a bad habit until it was redefined as a mental disorder. Yet another example is "excessive internet gaming" which is perceived by many as troublesome but has become a diagnosis in ICD-10.
Many experts now realize that diagnoses are invalid constructions. For example, the National Health Institute (NHS) (https: //www.nih.cov) has proposed new criteria for research precisely because the current diagnoses are not valid and for that reason obstructs research rather than promoting it. Even invalid diagnoses can be helpful if they do what they are meant to do, namely, predict the natural causes of the client's mental problems and guide the treatment.
Professor, psychiatrist and editor-in-chief of the world's most renowned psychiatric journal «World Psychiatry» Mario Maj at the University of Naples says the following in a lecture on 27 September 2016 at the Nazionale dei Giovani Psichiatri della SIP in Cagliari, Italy):
“It is becoming increasingly evident that the influences of diagnostic categories in psychiatry have been over-emphasized. These categories have initially been charged with implications in terms of pointing to specific treatment and prospectively a specific etiology and / or pathogenesis incomplete analogy with other branches of medicine. More recently they have been more modestly charged with relative not absolute pragmatic implications in terms of guiding the formulation of a management plan and the prediction and outcomes, the two main elements of clinical utility. 2017 Unfortunately, even these more modest implications of diagnostic categories in psychiatry have turned out to be overestimated. This is not to say that current diagnosis does not have clear implications, in terms of treatment-choice and predictions of outcome. The fact is however that these implications are less significant than originally believed and still assumed by most treatment guidelines”
What exactly is the purpose of diagnosing mental health problems as they are practiced today? Within current treatment practice, it may appear marginally necessary to have a good understanding of the client's mental problems as a symptom of common underlying causes. Clients who are sad and desperate differ greatly from each other despite the same diagnosis. Individuals who hear voices are not necessarily the same either, and people who use too much alcohol do so for different reasons and they need different and more individual and tailored solutions to experience recovery from their mental problems.
We must move away from a "one-size fits all model" and back to an individual-oriented psychiatry where help is more tailored to the individual client's needs (Aarre, 2018a). Neither the symptoms of diagnoses nor treatment appear to be very specific. They seem to lack accuracy in most treatment options (Frances, 2013; Gøtzsche, Smith, & Rennie; B. Whitaker, 2002). We must return to a psychiatry where the individual client's real perceived needs become the starting point for the treatment offer. Such an approach is more compatible with empowerment thinking which I believe should have a greater place in mental health work (Askheim, 2009, 2010, 2012). Empowerment will be a prerequisite for achieving real user participation. User participation from an empowerment perspective is about equal interaction between professionals and the client. From an empowerment perspective, one party will not be able to put its knowledge above the other. Empowerment presupposes that the participants have common interests in understanding each other's intentions. The professionals must give up power, move away from the expert role and to a greater extent move on to become partners with the clients. User participation in an empowerment perspective represents a paradigm shift which means that clients' knowledge is given increased status and influence.
Do we really know the cause of people's mental problems?
We do not always know the reason why people experience mental health problems. We also do not know if these mental problems and disorders really exist. There is no one-size-fits-all treatment that works for everyone. We are not in the position that we can say so much about forecasts apart from a general estimate that some will be good, some will not be so good, and some will never be good. It seems as if the client, in a way, falls between the bark and the wood. In other words, we are really groping in the dark.
The question is, what are we going to do with all this uncertainty? I do not mean to say that we do not know anything, on the contrary, we have a lot of knowledge and expertise, but the answer to the most fundamental questions remains unanswered. In psychiatry, we should continue with much of the good work that is being done but stop claiming that we know more than we actually do. We probably know a lot about a lot, but not as much as we could wish for and need. For example, we know a lot about the causal relationship to mental problems, but less about how it can be treated adequately.
We are good at somatic treatment, and we are good at regulating the relationship between the client and the clinician, so not everything is dark; There is a sun that shines behind dark clouds. On the other hand, what we do not know much about is what mental health problems are really about. We should probably ask the client himself, how he or she wants us to understand their mental problems and how they think we can help them. Many clients know a lot about themselves, and their circumstances and we should take their knowledge seriously. The client rarely is mistaken when he or she talks about his or her own condition and life. If we are to go for such an approach, this implies an acknowledgment that the client's mental problems are interconnected to the life they live including their past.
It is the client who says that context and culture mean something. At the same time, it is difficult to see all this precisely because many professionals have been trained to work in a certain way with the client's mental problems. The way psychiatry diagnoses its clients is mostly independent of context and largely follows signs and symptoms. The very emphasis of diagnoses can interfere with how the client is evaluated.
Psychiatrist and Professor Emeritus at Duke University in the USA, Allen Frances (Frances, 2013) was the leader of the so-called "task force" for the diagnostic manual DSM-IV. Frances writes in "Saving Normal" that he was involved in creating three false diagnoses (epidemics): ADHD, Aspergers and Bipolar Disorder 2. Frances writes that he greatly regrets the fabrication of these diagnoses. These diagnostic epidemics multiply none other than the pharmaceutical industry (B. Whitaker, 2002; R. Whitaker & Cosgrove, 2015). Today, Allen Frances spends much of her retirement life making professionals aware that the diagnostic system does not provide any validity and that only "Big-Pharma" makes a gross profit on these diagnoses (Frances, 2013; Gøtzsche et al.; Paris; 2015).
Frances warns psychiatry, it must not expand its boundaries indefinitely. An uninhibited and unlimited diagnosis will lead to an inflation in diagnoses including normal behavior and overtreatment, which will divert attention away from the treatment of real mental problems (Frances, 2013).
In Saving Normal, Frances writes that psychiatric diagnoses are still based on erroneous subjective assessments, instead of objective biological tests. He further writes that DSM was meant to be a simple tool to describe mental phenomena, but that psychiatry has become too complicated and is shocked that making a diagnosis has become the same as evaluating a client, while diagnosing is only a small part of a more extensive work that needs to be done.
Mental problems are diagnosed based on the diagnosis manual. An immediate problem with this is that there is little professional support for what a mental illness really is (Kenneth S. Kendler & Parnas, 2012). The validity of the diagnostic manual is strongly questioned by many professionals (Gøtzsche et al.; Kinderman, 2014b; Paris, 2015). I would suggest a more pluralistic and contextual approach in the psychiatric treatment of mental health problems as a response to the uncertainty that prevails. The problem with current diagnosis and categorization practices is that the client's mental problems are interpreted independently of cultural and contextual factors (K.S Kendler et al., 2011). My question is, how can we offer a more humane psychiatry when it initially takes insufficient account of the cultural and contextual factors that play a significant role in the client's life?
Drug-free treatment
Many clients feel that professionals are trying to dominate them rather than help them. The impression is that both the treatment and the medication administrated are determined for them without their consent, without having been included and consulted in the decision-making processes that concern their own treatment. There are signals that the client is "stepped over the head" what psychiatry thinks is right for them. If so, this is an abuse of power that works poorly for most clients. In psychiatry, there should be greater openness to discuss alternative treatment options including drug-free treatment.
There should probably be more room for a more contextual, individual-oriented, and tailored treatment offer. A treatment offer where the client can co-decide whether he or she wants completely drug-free treatment, step-by-step discontinuation in combination with talk therapy or other alternatives.
Recovery is a relatively new drug-free treatment incentive in addition to the existing traditional treatment options. Recovery as a concept and area of knowledge has gained increasing interest in Norway in recent years. Especially in user environments and municipal mental health work, the recovery perspectives have been perceived as important for understanding mental health and in the development of more equal forms of collaboration between users and professionals. (Berg, Karlsson, & Stenhammer, 2013).
What we do know is that some universities were skeptical and partly against Recovery as a drug-free treatment offer. In recent years, this skepticism has reversed, and there is now a greater acceptance of Recovery as a treatment offer on a par with the traditional treatment offers. Clients are often not allowed to choose for themselves which treatment option they think is best for them. It is doctors, psychologists and other health professionals who make these decisions, and they mostly refer to the medical treatment options. I probably think that the client should to a greater extent be included in the design of treatment offered.
The prognosis for recovery is better when the client feels that the treatment offer is suitable for him.
Many clients want treatment free from medicalization. A treatment offer that involves less pressure and stress, and where you can work with your convalescence in a more individually adapted way. Many clients do not want to be medicated, they know, for example, that medication with certain barbiturates over time can contribute to severe neurological disorders, mood swings, insomnia, irritability, etc.
Patient organizations have also signaled that these drug-free treatment options should be based on the client's trauma history. To take the client's trauma history as a starting point is to take the contextual seriously. It is worrying that patient organizations have to put forward such demands on the client's paths, the burden falls on healthcare professionals.
We know what trauma does to people's mental health, but it seems that health professionals are reluctant to discuss such topics. It is a preference to focus on symptoms, not on causal factors and their contexts. I do not mean that we should stop diagnosing, it is after all a mandatory part of most treatment options. But we do not need to emphasize the diagnosis so much that it appears to be the most important thing in the course of treatment. Listening to the client is the most important thing, only he or she can tell where the shoe hits the most!
Since it is a mandatory part of the treatment process in the public sector, it can be a way to go and tell the client which diagnosis one thinks fits his or her problems and ask him or her what their problems are really about and what they think. we can do. I believe that if psychiatry is freer in its approach and choices, it will be possible to develop different, more client-friendly treatment alternatives that are more in line with what the client himself thinks, wants and needs - a more contextual and humane psychiatry.
Short summary
The biomedical model is based on the fact that the causes of the client's mental problems lie as an essence in the client. I am skeptical of this approach; it does not take sufficient account of the cultural and contextual factors. What about the contexts of social disorder that the client is a part of, what role do they play in the client's psychological, psychoemotional and psychosomatic development? We cannot fully understand the client and his or her psychological problems if we do not consider culture and context (Bateson, 1972; N. Bateson & Brubeck, 2016). We are each other's context and mental and relational problems do not arise in isolation from them (Anderson, 2013; Anderson & Gehart, 2007).
Johann Hari (Hari, 2019a) was not ill when he experienced anxiety and depression. He calls his mental ailments normal reactions to abnormal conditions. The biomedical explanatory model is probably unsuitable for explaining mental problems. The outcome of a biomedical explanation for unusual conditions in a person's life usually becomes a morbidity of normal reactions to abnormal events (Frances, 2013) and can lead to a diagnostic inflation.
In psychiatry, there is talk of a chemical imbalance in the brain as an explanation of the client's symptom expression and mental problems is proof of that. Such an essentialist perspective is in danger of ignoring cultural and contextual factors. The question should not be what is wrong with the client, but rather what has gone wrong with the client's life. If one overlooks the client's possible trauma problems, one thus also overlooks the cultural and contextual factors that play a significant role in the client's life.
Professor Anna Luise Kirkengen at the University of Oslo (Kirkengen, 2009) writes that "abusive children become sick adults." She documents a coherence between childhood traumas and psychological, social, and behavioral disorders in adulthood. Also, Professor Vincent Felitti and Dr. Robert Anda (Robert F. Anda et al.; R. F. Anda et al., 2002; Felitti, 2002; Felitti et al., 1998) document identical findings in ACE study.
The biomedical model may appear attractive. It tells the client about what is wrong with them and that they can be helped through medical intervention. In line with psychiatrist Trond F. Aarre and Professor Ekeland (Tor-Johan Ekeland, lecture at the House of Literature in Oslo 21 March 2019), I believe that psychiatry has difficulty fulfilling its promises (Aarre, 2018a). It is paradoxical that clients come again and again for help with the same problems. The only thing that changes is the amount of medication, which does not make a difference, but rather creates addiction (Peter Roger Breggin, 1983; Gøtzsche, 2016; Gøtzsche et al.).
As mentioned, the diagnostic system lacks validity (Frances, 2013; Gøtzsche et al.), And thus mental problems are not real entities in this world regardless of the observer's observation and interpretation (Maturana & Varela, 1987). The diagnostic system consists of constructions that do not consider the cultural, contextual, and societal changes (Hagen & Kennair, 2020). If psychiatry is to be able to help people adequately, the cultural, contextual, and societal factors of which the client is a part must be considered.
Professor Mario Maj believes that the diagnostic system and its significance is "over-emphasized". He believes that some changes have been implemented, but without any pragmatic significance in terms of prognosis and clinical outcome. In line with Professor May, I ask, what exactly is the purpose of diagnosing mental health problems in the way it is done today? A client who is sad and despairing, hears voices is not necessarily sick. According to Eleanor Longden, hearing voices can be understood as useful information (https://www.ted.com/talks/eleanor_longden_the_voices_in_my_head).
A turnaround operation in psychiatry is required, away from a decontextualized and "one-size-fits-all" approach to a more individual-oriented and contextual approach where help is tailored to the individual client's specific needs. Will such an individual and contextual approach sort out better clinical outcomes?
Litteratur
Anda, R. F., Felitti, V. J., Tendall, M., Van der Kolk, B. A., Redding, C. A., & Kanopy (Firm). The ACE study.
Anda, R. F., Whitfield, C. L., Felitti, V. J., Chapman, D., Edwards, V. J., Dube, S. R., & Williamson, D. F. (2002). Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatr Serv, 53(8), 1001-1009. doi:10.1176/appi.ps.53.8.1001
Anderson, H. (2013). Samtale, sprog og terapi : et postmoderne perspektiv. Kbh.: Nota.
Anderson, H., & Gehart, D. (2007). Collaborative therapy : relationships and conversations that make a difference. New York: Routledge.
Anderson, H., Gehart, D. R., & Anderson, H. (2007). Collaborative Therapy in Action : Bridging the Gap Between Theory and Practice. New York: Routledge.
Askheim, O. P. (2009). Verktøykasse for brukermedvirkning - implementering etter pilot: implementering etter pilotfasen : rapport august - 09. [Hamar?]: [s.n].
Askheim, O. P. (2010). Rehabilitering og empowerment. In (pp. S. 217-228). Oslo: Gyldendal akademisk.
Askheim, O. P. (2012). Empowerment i helse- og sosialfaglig arbeid: floskel, styringsverktøy, eller frigjøringsstrategi? Oslo: Gyldendal akademisk.
Bateson. (1972). Steps to an ecology of mind : collected essays in anthropology, psychiatry, evolution and epistemology. San Francisco, Calif: Chandler.
Bateson, N., & Brubeck, S. B. (2016). Small arcs of larger circles : framing through other patterns.
Berg, M., Karlsson, B., & Stenhammer, A. (2013). Recoveryorienterte praksiser - En systemisk kunnskapssammenstilling. NAPHA - Nasjonalt kompetansesenter for psykisk helsearbeid, 4.
Breggin, P. R. (1983). Psychiatric drugs : hazards to the brain. New York: Springer.
Breggin, P. R. (1993). Toxic psychiatry : Drugs and electroconvulsive therapy: The truth and the better alternatives. London: Fontana.
Breggin, P. R. (2008). Brain disabling treatments in psychiatry : drugs, electroshock, and the psychopharmaceutical complex (2. edition. ed.). New York, NY: Springer.
Breggin, P. R., & Cohen, D. (1999). Your drug may be your problem : how and why to stop taking psychiatric drugs. Reading, Mass.: Perseus Books.
Burns, D. M., United States. Office on Smoking and Health., & Center for Disease Control. (1979). Involuntary smoking. Rockville, Md.
Washington: Dept. of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health for sale by the Supt. of Docs., U.S. Govt. Print. Off.
Burr, V. (2015). Social constructionism (2nd ed.). London ; New York: Routledge.
Dube, S. R., Anda, R. F., Felitti, V. J., Edwards, V. J., & Croft, J. B. (2002). Adverse childhood experiences and personal alcohol abuse as an adult. Addict Behav, 27(5), 713-725. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12201379
Felitti, V. J. (2002). [The relationship of adverse childhood experiences to adult health: Turning gold into lead]. Z Psychosom Med Psychother, 48(4), 359-369. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12407494
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med, 14(4), 245-258. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/9635069
First, M. B., Frances, A., & Pincus, H. A. (1995). DSM-IV handbook of differential diagnosis. Washington: American Psychiatric Press.
Frances, A. (2013). Saving normal : an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life (1. ed.). New York, N.Y.: William Morrow.
Gergen, K. J. (1969). The psychology of behavior exchange. Reading, Mass,.
Gergen, K. J. (2000). The saturated self : dilemmas of identity in contemporary life ([New edition]. ed.). New York: Basic Books.
Gergen, K. J. (2001). Social construction in context. London: SAGE.
Gotzsche, P. C. (2016). Antidepressants are addictive and increase the risk of relapse. BMJ, 352, i574. doi:10.1136/bmj.i574
Gøtzsche, P. C., Smith, R., & Rennie, D. Deadly medicines and organised crime : how big pharma has corrupted healthcare.
Hagen, R., & Kennair, L., Edward, Ottesen. (2020). Psykiske Lidelser. Oslo: Gyldendal.
Hari, J. (2019a). Lost connections : uncovering the real causes of depression-- and the unexpected solutions.
Hari, J. (2019b). Lost connections : why you're depressed and how to find hope ([New paperback ]. ed.). London: Bloomsbury Publishing.
Hertz, S. (2008a). Børne- og ungdomspsykiatri : nye perspektiver og uanede muligheder. København: Akademisk forlag.
Hertz, S. (2008b). Børne- og ungdomspsykiatri : nye perspektiver og uanede muligheder (1. udgave. ed.). Kbh.: Akademisk.
Insel, T. R., & Quirion, R. (2005). Psychiatry as a clinical neuroscience discipline. JAMA, 294(17), 2221-2224. doi:10.1001/jama.294.17.2221
Kendler, K. S., & Parnas, J. (2012). Philosophical issues in psychiatry. III, The nature and sources of historical changeInternational perspectives in philosophy and psychiatry (First edition. ed., pp. xix, 380 pages). Retrieved from https://login.proxy.lib.duke.edu/login?url=https://ebookcentral.proquest.com/lib/duke/detail.action?docID=1811850
Kendler, K. S., Zachar, P., & Craver, C. (2011). What kinds of things are psychiatric disorders? Psychological Medicine, 41)(6), 1143-1150.
Kinderman, P. (2014a). A prescription for psychiatry : why we need a whole new approach to mental health and wellbeing.
Kinderman, P. (2014b). A prescription for psychiatry : why we need a whole new approach to mental health and wellbeing. Basingstoke: Palgrave Macmillan.
Kirkengen, A. L. (2009). Hvordan krenkede barn blir syke voksne. Oslo: Universitetsforl.
Maturana, H. R., & Varela, F. J. (1987). The tree of knowledge : the biological roots of human understanding. Boston: Shambhala.
Maturana, H. R., & Varela, F. J. (1998). The tree of knowledge : the biological roots of human understanding (Rev. ed.). Boston, Mass.: Shambhala.
Moncrieff, J. (2008). The Myth of the Chemical Cure A Critique of Psychiatric Drug Treatment(1st ed., pp. 1 online resource (291 p). doi:10.1007/978-0-230-58944-5
Paris, J. (2015). Overdiagnosis in psychiatry : how modern psychiatry lost its way while creating a diagnosis for almost all of life's misfortunes. Oxford: : Oxford University Press.
Romer, A. L., Knodt, A. R., Houts, R., Brigidi, B. D., Moffitt, T. E., Caspi, A., & Hariri, A. R. (2018). Structural alterations within cerebellar circuitry are associated with general liability for common mental disorders. Mol Psychiatry, 23(4), 1084-1090. doi:10.1038/mp.2017.57
Wakefield, J. C. (1999). Evolutionary versus prototype analyses of the concept of disorder. J Abnorm Psychol, 108(3), 374-399. doi:10.1037//0021-843x.108.3.374
Whitaker, B. (2002). Mad in America : bad science, bad medicine, and the enduring mistreatment of the mentally ill. Cambridge, Mass.: Perseus Publishing.
Whitaker, R. (2010a). Anatomy of an epidemic : magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Crown Publishers.
Whitaker, R. (2010b). Mad in America : bad science, bad medicine, and the enduring mistreatment of the mentally ill(Rev. pbk. ed., pp. xviii, 348 p.). Retrieved from https://getitatduke.library.duke.edu/?sid=sersol&SS_jc=TC0000439214&title=Mad%20in%20America%20%3A%20bad%20science%2C%20bad%20medicine%2C%20and%20the%20enduring%20mistreatment%20of%20the%20mentally%20ill
Whitaker, R., & Cosgrove, L. (2015). Psychiatry Under the Influence : Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave Macmillan US.
Aarre, T. F. (2018a). En Mindre Medisinsk Psykiatri: Universitetsforlaget.
Aarre, T. F. (2018b). Serotonin or society? Tidsskr Nor Laegeforen, 138(11). doi:10.4045/tidsskr.18.0209