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A Less Medical More Client Friendly Psychiatry-Context and Culture does matter in Treatment

Oppdatert: 30. nov. 2021

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,


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.


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.


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 ( 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 cou