January 1999
Ok, so it’s about a month into this internship thing and I still
cannot get used to it. Today in ward round I felt like I was
attending a court case. It was like the patient was being
charged with an offense and we were kind of like expert
witnesses. I think Dr. S. was the judge. The registrar kept
saying things like, “ The patient denies experiencing
hallucinations .... the patient admits to having had suicidal
ideation ... the patient denies alcohol abuse..” I’m not sure why
they use this kind of language.
INTRODUCTION AND INVITATION
“Truth is one, but sages call it by various names”
Rig Veda.
“We know that many of our impressions are fragile. We realize the value of objectivity and calm, ordered study. We know that research is a fascinating combination of hunches, speculation, subjectivity, imagination, hopes, and dreams, blended precisely with objectively gathered facts tied down to the reality of a mathematical science. One without the other is incomplete. Together, they inch along the road in search of truth, wherever it may be found” (Axline, 1964, p. 15).
The chosen topic of this research is what are commonly known as ‘ward rounds’, in the psychiatric institutions of South Africa. The journey into this research is laden with the author’s “hunches, speculatio n, subjectivity, imagination, hopes and dreams...”, mixed together with an attempt “to inch along the road in search of truth” (Axline, 1964).
As Keeney (1982) maintains however, ‘truth’ as a concept, is difficult to define. Rather than being rational, causal, objective and universal (as the modernists suggest), it appears that ‘truth’ can be multidimensional, or multi-faceted and even localised (Hoffman, 1990).
As such, this dissertation is an attempt to explore different versions of various truths, to explore people’s subjective realities, their own perceptions and the conversations which make up their narratives, which make up the truth of their inner worlds. These narratives are conjoined with the hunches, speculation, subjectivity, hopes and dreams of the researcher and as such, a co-constructed narrative is formed and presented to you, the reader, in the form of this conversation or dissertation.
This study thus serves as an exploratory search and inquiry into the perceptions of patients during the process of the psychiatric ward round. It is not an attempt to be a definitive study regarding patient’s perceptions, and is not intended to suggest that such perceptions are uniform or constant. Thus, in line with the social constructionist paradigm, the researcher wishes to point out that this study claims to be neither definitive, nor applicable to all similar contexts. It is simply an exploration of perceptions and ideas.
It is also an invitation to you – the reader – to come along on this journey and explore with the researcher, the various attitudes, perceptions and truths of various individuals who have experienced the psychiatric ward round within the context of institutionalisation and within the broader context of the medical model. It is an invitation to converse with the text and in the process, to form your own perceptions, your own narrative and finally, your own truths.
THE PSYCHIATRIC WARD ROUND
The definition or understanding of “Psychiatric Ward Rounds” that is used in this study, is as follows: A multidisciplinary team meets regularly in a designated room of the hospital to diagnose and/or discuss the progress of different patients. The team is usually made up of a consultant psychiatrist, a registrar, a clinical psychologist, an intern psychologist, nursing sisters, nursing students, a social worker and an occupational therapist. As there is a significant contingent of student mental health professionals involved in this process, there is obviously a didactic element or added pur pose to the nature of the ward round.
The physical set-up of the room usually works around a semi-circle, where the multidisciplinary team fill the chairs, in an arch like shape, facing the doorway. There is usually a single chair left empty for the patient, at the entrance of the room.
The ward round, which takes place within the context of the Medical Model, usually commences with the consultant psychiatrist reading from the chosen patient’s file. A brief introduction, including some of the patient’s history is usually relayed to the rest of the team,
using the system incorporated in the Diagnostic and Statistical Manual IV (American Psychiatric Association, 1994). The psychiatrist then continues to give a tentative multiaxial diagnosis regarding the patient in question. Sometimes members from the other disciplines comment on, or add to this information.
The empty chair at the doorway, is subsequently filled by the patient ‘under’ discussion, after a student nurse, or nursing sister, has been sent to fetch the patient from his or her ward. The patient is sometimes introduced, by the consultant, to the individual members of the team, after which the main thrust of the ward round commences.
The consultant usually conducts the ward round, asking the patient questions to determine how orientated he or she is. Then personal questions about him/herself are asked. After this, members of the multidisciplinary team are invited to take turns asking the patient questions which might be relevant to the patient’s diagnosis and/or recovery.
After the patient has been escorted out of the room by one of the nursing staff , the team begins to discuss the patient, commenting on his or her responses to questions and on his or her general attitude and behaviour, both in the ward round and during therapy groups in which the patient might have participated, on the ward.
AIM OF THE RESEARCH
The researcher’s aim is to explore perspectives of the ward round process, within the context of the psychiatric hospital. The approach adopted in this dissertation, is broadly that of a post-modern, social constructionist perspective. Such an approach includes the perspective of the observer as relevant to the research. Therefore short excerpts from the researcher’s diary are included in the text.
February 1999
Today there were a few new people admitted to the ward and
I was assigned one of them. Her name is Anna. She is really
young. They say she is psychotic, but they don’t know if she has
bi-polar or schizophrenia. They want me to do some tests and
stuff with her.
Anyway, in the ward round this morning everyone was trying to
figure out the diagnosis. Then suddenly, Anna started shouting
at Dr. S. she said “Stop staring at me like that!” Then she went
up to one of the student nurses in the group and called her
‘Nonnie’. She asked Nonnie to take her out of the room, so this
girl got up and walked Anna out.
The sister in charge said that her name was not ‘Nonnie’. Dr. S.
said that Anna must have confused her with someone else.
What I think was interesting is that Nonnie was the only person
in the room who wasn’t staring at Anna, trying to figure her
out.
Researcher’s
Diary
PART TWO – EXPLORING THE
LARGER CONTEXT OF THE WARD
WHAT IS ‘ABNORMAL’ BEHAVIOUR?
INTRODUCTION TO THE MEDICAL MODEL
In most general terms,
we are all much more simply human than otherwise,
be we happy and successful, contented and detached,
miserable and mentally disordered or whatever.
Harry Stack Sullivan.
There are many differing viewpoints concerning what constitutes psychological abnormality. This study takes place within the context of the psychiatric institution and as such, it is the psychiatric classification of abnormality that I intend to explore.
Daffue (1992) argues that, “Any exploration of a subsystem in the health-care service must take the larger system under which it functions into account” (Daffue, 1992, p. 84). Mental or psychiatric institutions are a subsystem of a larger context or paradigm known as the ‘Medical Model’.
Kazdin, Bellack and Hersen (1980) explain the ‘medical’ definition of abnormality. They maintain that when one’s behaviour is excessively deviant, maladaptive or personally distressing, that one is then suffering from specific symptoms. These symptoms reveal that the individual suffers from some underlying biological disorder or state. Indeed, as Kazdin ,
et al., point out, “Many disorders in abnormal psychology are known to have a biological basis…” (Kazdin et al., 1980; 11).
The medical model views abnormal behaviour as a disease, that should be conceptualised and treated medically (Bootzin, Acocella & Alloy, 1993). As is the case with physical ailments, clusters of symptoms are defined as ‘syndromes’. Research is then conducted in order to ascertain the etiology of the syndrome, because as Sahakian, Sahakian & Sahakian Nunn, 1986 note, the cause of the ailment should put the researcher well on his/her way to detecting a cure for the ailment.
Proponents of the medical model generally agree that genetic factors, the central and peripheral nervous systems and the endocrine systems (which are all biological functions) interact with each other (and with environmental influences) to determine one’s behaviour. Once they have determined which biological factors are causing a specific syndrome, researchers will begin to seek a cure (Kaplan, Saddock & Grebb, 1994).
WHAT THE MEDICAL MODEL
ATTEMPTS TO ESTABLISH
The medical model attempts to determine (through family, twin and adoption studies) the degree to which specific disorders are inherited. It ha s already established that Down’s syndrome has a clear – cut genetic cause and that other disorders, such as schizophrenia seem to result from the interaction of environmental stressors and an inherited predisposition to the disorder (Kaplan, et al., 1994)
Pihl, Peterson and Finn (1990) for instance maintain that sons of male alcoholics are at markedly heightened genetic risk for the development of alcohol abuse. They are
characterized by abnormal patterns of cued psycho physiological response and appear more sensitive to the putatively reinforcing aspects of alcohol intoxication. This would indicate that there is a biological link to the ‘disease’ of alcoholism.
Apart from studying genetic inheritance, the medical model also studies one’s biological functions to see how these impact on disorders and disease.
HOW DOES ONE’S BIOLOGICAL FUNCTIONING
AFFECT ONE’S PSYCHOLOGICAL FUNCTIONING?
THE CENTRAL NERVOUS SYSTEM
Of at least fifty neurotransmitters that are thought to operate along neural pathways within the central nervous system, nine have been implicated in various psychological disorders and four play a critical role in psychopathology. Scientists have however discovered specific drugs, which can be used to correct suspected malfunctions of the body’s neurotransmitters.
THE BRAIN
The brain is divided into two symmetrical hemispheres, each containing four lobes with differentiated functions. Psychological disorders have been traced to dysfunctions in many of these brain structures, as well as to dysfunctions related to brain lateralization. Some
researchers suspect that Schizophrenia may be partly explained by left – hemisphere dysfunction. It is also suspected that right hemisphere dysfunction may add to emotional disturbances such as anxiety and depression.
THE PERIPHERAL NERVOUS SYSTEM
The autonomic nervous system, which makes up part of the peripheral nervous system, is associated with stress-related disorders, such as hypertension, ulcers and insomnia.
THE ENDOCRINE SYSTEM
The endocrine system influences emotional states, sexual functioning, physical development and the level of available energy by releasing hormones into the bloodstream, from the endocrine glands. It is also believed that glandular dysfunction may be partly responsible for severe depressive disorders
(Kaplan, et al., 1994).
THE NATURE OF DIAGNOSIS AND TREATMENT
In order to gain a better understanding of how the medical model actually works, it is useful to view it in practice, seeing how proponents of the medical model assess mental ‘illness’ and how they would eventually treat it.
Generally, clinical assessment usually includes diagnosis, where one’s problem is classified within a set of recognized categories of abnormal behaviour and labeled, within the
taxonomy of disturbances, developed by the psychiatric profession (Bootzin, et al., 1993).
Given its organic focus, the medical perspective favours assessment methods that reveal organic structure and function. Imaging procedures such as Computerized Axial
Tomography (-or CAT SCAN – a type of computer x-ray of the brain), ‘Position Emission Tomography (-or PET SCAN – where the progress of radioactive particles, through the brain, is traced) and ‘Magnetic Resonance Imaging’ ( - or MRI SCAN– where magnetic fields present a precise picture of the brain) are usually made use of (Rosehan & Seligman, 1989).
Although both the CAT and PET have already produced important findings with regard to schizophrenia, and the MRI is being used to aid major new discoveries; progress is slow and medical assessment still depends heavily on psychometric testing which reveals performance deficits (Kaplan, et al. 1994).
Biological treatment of psychological disorders has received much support in the last decade, following suggestive evidence of the biochemical bases of disorders such as
Schizophrenia and Depression. Treatments range from psychopharmacological (or drug treatment) to electroconvulsive therapy (or ECT) and psychosurgery (Kaplan, et al., 1994).
The three main categories of drugs are anti-anxiety drugs, which provide effective temporary relief from panic attacks or anxiety, but which can be harmful if taken too often;
antipsychotic drugs, which help to reduce symptoms of schizophrenia (for example), but may produce side effects of apathy, fatigue and motor disturbances; antidepressant drugs and anti-convulsant drugs (which work effectively to relieve, symptoms of mania and depression, especially in patients with a Bipolar disorder (Rosenhan & Seligman, 1989).
ECT works in a similar manner to antidepressant drugs, but as it is considered a controversial form of treatment (it is known to cause memory dysfunction), it is not a popular form of therapy, while psycho-surgery, a very severe form of ridding an individual of ‘abnormal behaviour’, is apparently only used as a last resort for severely disturbed or violent patients (Kaplan, et al., 1994).
PSYCHOTHERAPY AS A FORM OF TREATMENT
WITHIN THE MEDICAL MODEL
Clinicians argue about the question of whether or not psychotherapy falls within the
framework of the medical model. Some researchers feel that psychology and psychotherapy (with all its varying schools of thought) fits into the epistemology of the medical model, while others tend to place it in the paradigm of social science and see it as separate from the medical field (Breggin, 1993; Kleinman, 1988)). Some see certain schools of thought as being aligned with the medical model and others as contradictory to the medical model (Breggin, 1993). For the purposes of this dissertation however, this question will not be addressed in detail.
Webster (1989) in her study of the interdisciplinary team notes that although the dominant organising principles within the interdisciplinary team are those of the medical model, most patients do receive some form of psychotherapy while institutionalized.
Webster (1989) continues to point out that within the institutional setting, many different schools of psychology are represented. In 1988, she maintains, there were at least four schools of thought represented among psychologists working at the Sterkfontein Mental Hospital. These different paradigms were embodied by the psychoanalytic school, the behaviorist school, the client-centered school, and the interactional school of thought (Webster, 1989).
Albee (in Foudraine, 1974) reports discomfort regarding the position that psychologists have occupied in medical centres and mental institutions. According to Albee (in Foudraine, 1974), “....clinical psychologists have been ‘honoured’ guests, obedient slaves who adopted the values and language of their (medical) masters. They too talked about ‘patients’ with ‘diseases’ that require ‘treatment’ ” (Foudraine, 1974, p. 364).
March 1999
Today in ward round, the patient on trial was a woman called
Marta. She must have been in her late fifties. Anyway, She sat
through the ward round and refused to answer any personal
questions! She said that she felt very vulnerable and was not
comfortable answering intimate, personal questions in front of
a panel of people that she did not know. She told us to get her
file from the previous hospital, `cause she reckoned that all
the information would be in there.
Me and Mr. B. thought this was the greatest thing `cause she
was actually protecting herself in a way and keeping her
dignity. We kind of smirked about it which we probably
shouldn’t have done, `cause Dr. S. looked so annoyed. Anyway,
Mr. B. told him – maybe she has really healthy boundaries? But
Dr. S. wrote in her file, that she was resistant and paranoid.
Researcher’s
Diary
PART THREE - HISTORY OF THE
MEDICAL MODEL
THE RISE OF THE MEDICAL MODEL
The medical model is a popular paradigm through which to view abnormal behaviour (Bootzin, et al., 1993). To understand why it has gained so much support and credibility, it is important to note the model’s development over the years.
Early societies seem to have viewed abnormal behaviour as the product of supernatural forces (Kazdin, et al., 1980). Individuals who behaved strangely were either thought to be possessed by demons, to be witches, devil worshippers, or otherwise, to be victims of G-d’s punishment. If one’s behaviour was seen to be threatening, one was then a candidate for chains, dungeons, torture, and even death (Foudraine, 1974).
A more scientific approach to abnormality came about though, in Ancient Greece. The physician, Hippocrates, observed and recorded cases of mental disturbance. He developed an organic theory of abnormal behaviour (believing that personality disorders were due to an imbalance among four ‘humors’, or vital fluids in the body: phlegm, blood, black bile and yellow bile). He then attempted to classify abnormal mental states and adopted humane methods of treatment. His approach lasted until the fall of the Roman Empire, in the fifth century AD, and although it may seem primitive to some, Hippocrates’ theories
foreshadowed today’s physiological and biochemical research in abnormal psychology (Bootzin, et al., 1993).
It was only in the late nineteenth century that a scientific or medical approach to abnormality was again adopted. Wilhelm Wundt and his student, Emil Kraeplin, began to apply scientific methods to the study of human thought, and behaviour – this work, along with the research of other scientists, brought the medical model to the forefront. Indeed, it was Kraeplin in 1883, who contended that mental illness, like physical illness, could be classified into separate pathologies, each with a different organic cause and each with its own group of symptoms (Rosenhan & Seligman, 1989).
It was also around this period that Richard Von Krafft Ebbing, discovered that the illness ‘general paresis’, which involved the gradual and irreversible breakdown of physical and mental functioning, was actually an advanced case of syphilis, where syphilitic
micro-organisms had passed through the bloodstream and into the central nervous systems and the brain. It was this discovery that mainly impacted on the mental health profession, eventually establishing the support it holds today (Rosenhan & Seligman, 1989).
The rise of the Medical Model seemed to bring with it improvements in the treatment of those who displayed abnormal behaviour. As victims of an illness, they were thus viewed with more sympathy and less hatred and fear (Porter, 1987). As our journey through the Medical Model unfolds, however, we shall begin to see that conditions of treatment were unfortunately, still far from humane.
THE RISE OF THE PSYCHIATRIC INSTITUTION
The practice of hospitalizing the mentally disturbed is a very ancient one. In Arab countries, general hospitals provided wards for the psychologically disturbed as early as the eighth century. Mental patients were also accepted in some European hospitals of the Middle Ages and the Renaissance. However, the first hospital exclusively for the mentally ill opened in Muslim Spain in the early fifteenth century. This example was then followed in other countries too. Mental hospitals were founded in London, Paris, Vienna, Moscow, Philadelphia, as well as in other major cities around the world (Porter, 1987).
Early mental hospitals have been described in chilling terms, often with the assertion that these institutions did not aim to cure, but only to isolate - and often humiliate - the insane (Foucault, 1965; Scull, 1979). Apparently most of these institutions were opened with the best of intentions, but these hospitals were known for placing patients in notorious
conditions. As social historians note, most patients were chained and kept in dark dungeons, away from the eyes of the more ‘normal’ or ‘civilized’ society (Foucault, 1965; Foudraine, 1974).
Allderidge (1985) who researched London’s notorious Bethlem Hospital (often referred to as ‘Bedlam’, due to its reputation for producing torturous circumstances that were reflected in the screams of its patients) maintains however, that the stated ill treatment of these early institutions came about not due to excessive cruelty, or a ‘policy of abuse’ but rather due to the fact that attendants had difficulty handling violent patients and were uncertain of how best to treat them (Allderidge, 1985). The situation, nevertheless resulted in cruel treatment and assured that the ‘insane’ were isolated from the rest of society.
REFORM IN THE INSTITUTIONS –
THE BEGININGS OF ‘MORAL TREATMENT’
Although it is not very well known, the first serious efforts to improve treatment in large hospitals began in the late eighteenth century with a man called Vincenzo Chiarugi. He was the superintendent of the newly opened Ospedale di Bonifazio, a hospital for the mentally ill in Florence. In 1789, Chiarugi published regulations stressing the need for humane treatme nt (Maher & Maher, 1985).
The most famous instance of reform, however, which took place at roughly the same time as Chiarugi’s initiative, occurred at La Bicetre, a large hospital in Paris (Foudraine, 1974). Jean -Baptiste Pussin, who was superintendent of the ‘incurables’ ward, laid down new rules for
the staff, upon acceptance of his post. Staff were forbidden to beat patients and were also ordered to unchain many groups of patients (Foudraine, 1974, Porter, 1987).
Pussin’s attempts at reform were further extended by Philippe Pinel, who took the position of chief physician at La Bicetres in 1793 (Foudraine, 1974). Pinel perceived the mentally ill as ordinary human beings who had been deprived of their ability to reason, due to severe personal problems . He took the stance that to treat patients as animals, was not only inhumane, but also obstructive to their recovery. Pinel eventually replaced the dungeons with airy, sunny rooms and forbade violent treatments such as bleeding, purging and cupping. He also spent many hours talking with the patients, listening to their problems, and giving them comfort, support and advice. Not surprisingly, many of these patients suddenly became more ‘manageable’ (Porter, 1987).
Pinel kept records of the conversations he had with various patients and eventually began to develop case histories, a record, or a narrative for each one of them. This practice of record keeping introduced by Pinel, is considered an extremely important innovation, by the medical profession, as it allowed practitioners to chart the characteristic ‘patterns’ that emerge in the course of various disorders (Bootzin, et al., 1993). On a more ‘therapeutic’ note, this might also be seen as the beginnings of early narrative work (!).
After Pinel’s retirement, Jean Esquirol, his student and successor, continued the reform movement. He founded ten new mental hospitals in various parts of France. These hospitals were all based on the humane treatment that had been developed by Pussin and Pinel (Bootzin, et al., 1993, Porter, 1987).
At roughly the same time that Pussin and Pinel were busy with their reforms in France, a Quaker known as William Tuke was attempting similar reforms in Northern England. In 1796, Tuke moved a group of mental patients to a rural estate, called ‘York Retreat’. There patients ‘talked out’ their problems. They also worked, prayed, rested and took walks through the countryside. Tuke was specifically opposed to treatments which he felt might be
likely to ‘degrade the feelings of patie nts’ (Rosenblatt, 1984). As can probably be expected, the recovery rate at York Retreat was high.
These new techniques eventually became widespread, under the name of ‘moral therapy’ or ‘moral treatment’. Based on the theory that the mentally ill were just ordinary people with extraordinary problems, moral therapy aimed at restoring the ‘morale’ of patients, by providing an environment in which they could discuss their difficulties in peace. More than anything else however, moral therapy aimed at treating patients like human beings (Peterson, 1982; Porter, 1987).
Research indicates that this approach was extremely successful. Contemporary records point to the fact that during the first half of the nineteenth century, when moral therapy was the only treatment provided by mental hospitals in Europe and America, at least 70 percent of patients who had been hospitalized, either improved or actually recovered (Bockoven, 1963).
The reform movement in American mental health establishments was lead by Benjamin Rush (1745-1813), who moved American psychiatry in the direction of humane therapy. Rush would recommend that doctors regularly bring small presents such as fruit or cake to their patients. He also insisted that hospital attendants read to patients, talk wit h them and generally share in their activities (Porter, 1987).
MORE REFORM IN THE INSTITUTIONS –
THE DECLINE OF ‘MORAL TREATMENT’
Dorothea Dix, a Boston school teacher who visited York Retreat and other similar institutions abroad, also became convinced of the need for reform in American
establishments. According to Foucault (1965) however, Dix unwittingly and unintentionally contributed to the decline of Moral Therapy.
In the early 1800’s in America, the mentally ill were housed in jails and poorhouses, or were left to wander the countryside. In the 1840’s however, a number of state funded mental hospitals began to emerge through the efforts and public insistence of Dorothea Dix (Foudraine, 1974; Weiten, 1998). The new hospitals were supposed to provide humane and effective treatment for patients, however they were largely under funded and
understaffed (Bloom, 1984; Scull, 1990).
As hospital after hospital opened, patient populations increased, while hospital staff became scarce. This situation prevented the sort of tranquil atmosphere and individual care essential to moral therapy. Moral therapy began to fall into disuse. Recovery rates dropped
considerably and did not rise again for many decades (Bockoven, 1963).
The state mental hospital system grew rapidly with the rise of the medical model. The early success of the medical model caused psychiatric professionals to become convinced that their efforts should be directed toward biological research, rather than toward creating the therapeutic environments typical of moral treatment. The medical model also convinced mental health workers that patients should not be released until they were ‘cured’. As the years passed, more and more beds were thus occupied by chronic, long-term patients, who never got better and who thus never left the hospital (Bootzin, et al., 1993).
Sadly, the philosophy behind moral therapy was forgotten. Patients were walled off in somber isolation in rural areas and the public unlearned the previous perception, that the mentally ill were ordinary people. Public opinion tended to focus on the thought that some freakish, dangerous, dark horror was being concealed, behind high walls, (Breggin, 1993).
AND YET MORE REFORM - DEINSTITUTIONALISATION
The use of new drugs, such as major tranquilizers and anti-psychotics, was implemented in the institutions. This proved to be a milestone in the history of treatment. It lent even more
support to the medical model (Breggin, 1993), and yet subsequently also lead to the reduction in numbers of institutionalized patients in recent years (Szasz in Soderlund, 2001).
Apart from the advent of the new ‘miracle’ drugs, other factors started to influence the way institutions were run. After World War Two, major transitions in the history of psychiatric institutions began to take place (Porter, 1987).
Amongst the reasons for these changes, was the fact that research indicated that hospitalisation often contributed to the development of pathology instead of curing it (Mechanic, 1980).
Researchers bega n to notice that long-term patients within mental institutions were taking on a ‘passive patient role’ and that their ability to manage their lives began to decline instead of improve. Many patients became fearful of leaving the hospital and fearful of taking
responsibility for their own lives. Thus the medical model, in the form of the psychiatric institution, had created a type of dependency in patients (Korchin, 1976).
Another problem appeared in the fact that patients had been uprooted from their
communities and sent to far away, rural institutions. They had often lost contact with their family, friends and employers. This then made it difficult for them to return to their communities and assume responsibility for their own lives. It fed into the depend ency that the mental institutions had created (Porter, 1987).
Disenchantment with the institutional system lead to the uprising of the community mental health movement. This movement focused on creating local, community based care with reduced dependence on hospitalisation. It also worked on the premise that one should attempt to prevent the occurrence of psychological disorders, rather than attempt to ‘cure’ them (Weiten, 1998).
This movement in turn encouraged the development of community mental health centres, which aimed to provide a decentralized, more accessible service to sufferers of mental
illness. The community centres offered specific services such as short-term, local inpatient care; extensive outpatient therapy; crisis intervention services and a focus on community education regarding mental health.
As people were released from the various institutions, problems started to become apparent. Communities were not able to fund and build the planned facilities, such as halfway houses and sheltered workshops, that were intended to help previous patients get back on their feet. As a result, chronic sufferers had nowhere to go when released. Socially speaking, this situation is known to have exacerbated the problem of homelessness in America (Bassuk, Rubin & Bauriat, 1984; Breggin, 1993).
Some researchers have gone so far as to say that shelters have become ‘open asylums’, replacing the previous mental institutions. Indeed, a one day census of people using shelters in the Boston area in America, revealed that forty percent of guests had major psychiatric disorders (Bassuk, Rubin, & Bauriat, 1984).
Haywood, Kravitz, Grossman, Cavanaugh, Davis & Lewis (1995) maintain that deinstitutionalisation has also added to what is termed, the ‘revolving door syndrome’, where patients who have been treated for a short while, tend to frequently relapse and return.
Deinstitutionalisation was perhaps poorly executed (Szasz in Soderlund, 2001).
Overall it seems to have been of benefit to people with milder disorders, but cruel to people with severe, chronic disorders, who had become dependent on their status as patients and who now had no resources to fall back on (Breggin, 1993).
The general consensus seems to be however, that people do not want to revert back to the old system (Breggin, 1993; Szasz, 2001). Thus one suggestion is that this newer, community based system should be improved upon, in terms of the quality and availability of
most issues in life, however, the problem seems to boil down to finding funds (Foudraine, 1974).
September 1999
They’ve moved me to the male adolescent ward now. It actually seems a bit better here, they seem to be a bit gentler with the patients. The psychologist is leading these ward rounds and he always ends of by asking the patient, “Is there anything you would like to ask us?” I think this is much better.
Nevertheless, it is still a strange process and I’m still not 100% used to it. Even on this ward, where they are a bit gentler, the patients still seem so anxious about the ward round. Today there was a new admission – this kid called Mondli. When he walked in they told him to sit in the empty chair by the door – that’s the chair that they always put the patient in. Anyway he sat down and the ward round started. This poor kid was in the middle of a florid psychosis.
What was really interesting though, was that he actually got up, in the middle of the ward round and moved his chair! He put it alongside the others and kind of made himself, like a part of the group. I really thought that was fascinating, `cause he is supposed to be so sick, but he actually realised that socially he had been placed alone and was not part of the team. I thought that was quite perceptive, but Dr. W. said that it clearly demonstrates how sick he is, because it is socially inappropriate to get up in the middle of a meeting and move your chair.
Researcher’s Diary
PART FOUR – THE PHILOSOPHY
OF THE MEDICAL MODEL
THE PHILOSOPHICAL UNDERPINNINGS
OF THE MEDICAL MODEL
Webster (1989) maintains that conceptualizations of health and pathology are recursively linked to existing social circumstances and value systems prevailing at the time in question.
Hill (1981; 1983) explains how this has occurred in the history of mental health. Hill (1981) posits that since the time of Plato, two conceptualisations of ma dness have dominated the mental health field. These are the ideas that madness can be attributed to divine causes and/or that it is due to natural causes in the body (Hill, 1981). According to Hill, the concept of divine madness eventually led to the widespread belief in demon possession and to the cruel treatment of the mentally ill which characterised the Middle Ages (Hill, 1981).
Indeed, Hill (1983) observes that in the Middle Ages and the Renaissance, the need to maintain conformity and obedience was considered paramount to the survival of both the church and the state. He states that this authoritarian worldview perceived all forms of
non-conformity as evil. Madness fell into the category of non-non-conformity and was thus treated as such.
Hill (1983), in an article on the changing role of medicine in psychiatry, further elaborates that this authoritarian stance regarding ‘deviant’ behaviour, continued even into more recent times. He explains that misguided theories about the nature of insanity were used to back up further cruelty, in the form of ‘revolving chairs’, shock treatment, intense hydrotherapy and the administration of nauseous drugs.
Kleinman (1988) explains that our social and personal worlds are mediated by language, symbols, value hierarchies and aesthetic forms. These are the pervasive cultural apparatus which order social life. He maintains that psychiatry and psychology are not exempt from this dialectic. Psychiatric and psychological concepts, research methodologies and even data are emb edded in social systems. Kleinman explains that “....the work of the practitioner and the powers of the profession originate in the same dynamic systems of values and relationships and experiences. Through them, psychiatric diagnostic categories are constrained by history and culture, as much as biology” (Kleinman, 1988, p.4).
THE NEWTONIAN WORLD MACHINE
AND THE MEDICAL MODEL
The biomedical model is understood to be largely non-contextual, non-systemic and intrinsically mechanistic (Schwartz, 1982).
Gergen (in Kvale, 1992) maintains that these qualities embedded in our current view of mental health can be traced back to the philosophy of ‘Modernism’, or what is termed, ‘Positivism’ and also, ‘Newtonianism’.
This worldview or value system (Modernism) that lies at the basis of Western culture, has its roots in the scientific revolution of the sixteenth and seventeenth centuries, according to Capra (1983).
Gergen (in Kvale, 1992) explains that Modernism in Western culture may be linked historically, to the process of mechanization, and its close association with advances in science and technology (Gergen in Kvale, 1992; p. 18).
The fore-runners of the scientific revolution, which lies at the basis of Modernism, were Copernicus and Galileo. Both influenced the development of science significantly with the use of mathematical theories, which were thought to explain scientific laws (Capra, 1983).
Then there was Francis Bacon, who also had a profound influence on the development of science. Capra (1983) maintains that prior to Bacon, the goals of science had been to understand the natural order of the universe and to live in harmony with it. Since Bacon however, it seems that the goal of science has been to gather knowledge about the laws of nature, which can then be used to dominate and control nature (Capra, 1983).
The two most prominent figures however, who influenced scientific thought and thus, also the value system underlying Western culture, were Rene Descartes and Isaac Newton. The ideas of Copernicus, Galileo, Bacon and Descartes, were all put together and synthesized by Isaac Newton in his “Mathematical Principles of Natural Philosophy. The Principia” (Capra, 1983).
Capra (1983) and Joubert (1987) point out that the principles advocated by Newton (which are steeped in Cartesian philosophy) had far reaching effects, both on the development of the medical model of mental health as well as the various psychological models that are employed today.
Descartes, who is regarded by many scholars, as the fa ther of modern philosophy (Capra, 1983; Lindsay, 1912), is known for two main ideas that influenced modern thought. Firstly,
he popularized the notion that there is a distinct division between body and mind and secondly, he put forward the notion of nature as a machine, which is governed by exact mathematical laws (Capra, 1983; Lindsay, 1912).
Regarding the view of nature as a distinct and precise machine, Capra (1983) points out that Descartes, like Bacon, believed that everything in the material world could be explained and eventually predicted - if one understood the governing laws that run the machine.
Furthermore, he believed that one could understand and predict nature far more accurately if one understood the arrangement and movement of each of its specific parts. This idea is known as ‘reductionism’ (Capra, 1983).
Using the machine metaphor, Descartes compared the human body to that of a clock. He felt that a sick man could be compared to an ill made clock, whereas a healthy man might be compared to a well-made clock (Capra, 1983, p.47). This idea had a decisive influence on the development of the life sciences, where living organisms began to be seen as nothing but machines that could be understood if one dissected and examined their specific parts.
Joubert (1987) posits that the science of modern medicine is still based on the Cartesian notion of the body as a machine. The doctor’s (and often psychiatrist’s) work is seen as being that of repairing the specific parts of the ‘faulty machine’.
The medical model of disease, according to Ludwig, in Engel (1977), operates according to the premise that “....sufficient deviation from the normal represents disease, that disease is due to known or unknown natural causes and that elimination of these causes will result in cure or improvement in individual patients” (Ludwig in Engel, 1977, p. 130).
Health, according to the philosophy of the medical model, is defined negatively as being ‘the absence of disease’ and is perceived to be an all or nothing affair. This also means that disease is viewed as an enemy who needs to be defeated (Webster, 1989).
Descartes’ idea regarding the division or separation of body and soul, according to Joubert (1987), also encouraged the idea that ‘objectivity’ was possible. The separation of the material world from that of reason was seen as a reality, while objective description became the ideal of scientific practice (Joubert, 1987).
This philosophy is also known as ‘dualism’. Dualism holds that there is a complete division, or separation of mind from body - of the psychological from the somatic (Shwartz, 1982). It provides no context whereby mind and body can be related other than through (what has previously been introduced as) ‘reductionism’ (Engel, 1978).
Reductionism holds that in order to understand a more complex entity, it is best to divide it into smaller parts and then analyse these parts. According to Engel (1980), the medical model still works according to the doctrine of specific etiology, formulated by Koch. Koch postulated that specific diseases are caused by specific microbes within the body.
Reductionism maintains a view of nature as involving interactions of separate entities in a lineal causal fashion, thus advocating simple cause and effect relationships (Engel, 1980).
According to Kleinman (1988) the medical model offers a view of disorder in which biology is the foundation, and psychological and social dimensions of illness are seen as
epiphenomenalism, or superstructure layers that need to be stripped away to get at the ‘real’ cause or infrastructure, that is, the biological base (Kleinman, 1988).
THE BASIC TENETS OF MODERNISM
According to Gergen in Kvale (1992), at the core of modernism lies the belief that there is a ‘knowable world’. Modernism works in terms of boundaries, whereby each area of science must specify its domain of the knowable world that constitutes its subject matter and study this area separately from other areas (Gergen in Kvale, 1992).
In addition to presuming a knowable subject, modernism also adheres to a belief in universal properties. That is, it is presumed that there are principles, or laws, which may be
discovered about the properties of the subject matter. Modernism holds that the systematic study of single instances may then be generalized to other situations, across time, context and person. In effect, this philosophy is engaged in the development of empirically grounded theoretical networks with the potential for broad prediction (Gergen in Kvale, 1992).
Modernism has also been committed to a belief that truth is discovered through method. In particular, the theory is that by using empirical methods, and most particularly the controlled experiment, one can deduce universal truths about the nature of the subject matter and the causal networks in which it is embedded. It is also maintained that the results of such methodology is entirely impersonal. Modernism holds that such empirical methods prohibit the entry of ideology, values or passions into the description and explanation of relevant phenomena (Gergen in Kvale, 1992, p.20).
Lastly, it seems that modernism, or positivism, adheres to a belief in the ‘progressive nature’ of research. It holds that false, or incorrect beliefs can be abandoned, while science moves toward the establishment of reliable, value neutral truths about the various segments of the objective or knowable world (Gergen in Kvale, 1992).
These then are the basic principles upon which the medical model is based. It seems that most psychological models fall within the paradigm of the medical model, as psychology, like other domains of study, are generally embedded in the core beliefs of the Western world, which has at its base the theory of modernism (Capra, 1983) .
The influence of Newtonian concepts can be clearly seen, for example, in the theory of Freud. This is seen in the Freudian concept of ‘symptom formation’. Joubert (1987) cites Chessick, who relates that Freud seemed to think in terms of causality - as a germ causes sickness, so psychotrauma causes pathological behaviour. Chessick states further that “...Freud’s meta psychology was an attempt on the order of Newton to describe mental processes according to laws, incorporating the expansion of mental functioning to include
the unconscious, it was a Newtonian system complete with forces, energies, dynamics and so on” (Chessick in Joubert, 1987, pp. 38-39).
THE CONCEPTS OF DIAGNOSIS AND TREATMENT
The medical model focuses largely on diagnosis and treatment. According to Engel (1977), within the model, diagnoses are made by inferring causal connections. Then appropriate treatment and prognosis are discussed. Engel (1977) quotes Kety, who explains that according to the medical model, illness is not classified as a specific disease immediately. According to Sutker and Adams (1994), the classification of illness is seen as a process, moving from the recognition and palliation of symptoms to the identification of a specific disease, of which the cause and course are known (Sutker & Adams, 1994). Treatment is seen to be rational and specific (Engel, 1977).
The medical model therefore promotes this process of categorization, which proceeds from the naming of symptoms to clusters of symptoms, to syndromes and eventually to the naming of diseases with specific pathogenesis and pathology, which require specific treatment (Engel, 1977; Sutker and Adams, 1994).
Capra (1983) describes this model of health and pathology as a mechanistic model and views this approach to treatment as an engineering approach.
Goffman (1961) names the medical model’s approach to treatment, and in particular the concept of institutionalisation, as a ‘service’ model. His perception is that the expert gives assistance to a client who presents a particular object for repair. He feels that patients are admitted at hospitals, where psychiatrists aim to discover what is wrong with them and consequently treat the problem. This, he feels is similar to the process of a car being serviced at a workshop. The car is left at a service station, where the mechanic discovers what is wrong with it and consequently treats the problem. Goffman (1961), terms this the ‘workshop complex’.
As Webster (1989) maintains, the medical model works according to the principle that in order to ‘cure’ an illness outside intervention by a physician is required. This intervention can be either physical - through surgery or radiation, or chemical - through the use of drugs.
According to Capra (1983), intervention within the medical model, is carried out within the paradigm of reductionism, with the aim of correcting a specific biological mechanism in a particular part of the body. Different parts of the body are also treated by different specialists. Capra (1983) brings to light the fact that previously more than half of all physicians were general practitioners, whereas now over 75% are specialists, who focus their attention on a particular age group, disease, or part of the body.
Glenn (1984) likens this approach to the old belief in a single ‘magic bullet’. Such old style ‘magic bullet’ theories appear to have been based on the concept of cause-and-effect. The ‘magic bullet’ theory implies that once the etiology of a specific illness is identified and defined, the dysfunction could be cured by using a specific treatment approach which would not affect any other parts of the surrounding system (Glenn, 1984).
Thomas Szasz (in Soderlund, 2001) comments that modern treatment of so-called psychological disorders fits into the paradigm of the magic bullet approach. He gives the example of ADHD in children and explains that the diagnosis and chemical treatment offers parents and teachers the sense that they are doing something about the problem “.... that they are dealing with it in a rational, scientific way. It’s a kind of pharmacological magic” (Szasz in Soderlund, 2001, p. 14)
PART FIVE – PROBLEMS WITH
THE MEDICAL MODEL
INTRODUCTION
Writers such as Capra (1983), Engel (1978) and Szasz (2001) point to growing public and academic dissatisfaction with the medical model. Many problems within the model have been raised, both from a pragmatic stance, as well as from a more theoretical point of view.
THE PROBLEM OF ‘PSEUDO-SCIENCE’
On a practical level, the medical model has been criticized for a number of reasons. Some critics have pointed out the fact that psychology, in an attempt to try and align itself with other sciences, practices ‘inaccurate’ science (Coleman, 1991). Critics point to branches of experimental psychology, where a large amount of animal research is conducted. Apart from longstanding problems in terms of ethics, this is queried in many cases, as the human psyche is seen by many, to be vastly different to the animal psyche (Bootzin, Acocella & Alloy, 1993; Coleman, 1991; Weiten, 1998).
Indeed, Rapoport (1989) asks, when commenting on research methodology for Obsessive Compulsive Disorder “…can we localize ‘doubt’ or ‘will’? These notions preclude attempts to study the illness in animals. We must work with human patients to understand OCD.” (Rapoport, 1989, p. 91). This same argument could apply to the study of other disorders. We are not able to ask animals about their subjective experiences regarding hearing voices, for example. Although it seems that some researchers are not in favour of animal
experimentation, many researchers continue to conduct animal research in the name of ‘science’.
Other scientific critiques of the medical model within psychiatry and psychology, include issues such as the fact that technical – sounding diagnoses tend to provide a type of pseudo explanation of illness, that involves circular reasoning. For example: why does ‘x’ act that way? Because ‘x’ is schizophrenic. This answer does not explain why ‘x’ is schizophrenic (Foudraine, 1974; Weiten, 1998).
According to Kleinman (1988), non-Western cultures make up a very large portion of humanity, yet they occupy a very silent presence in the face of psychiatry. Kleinman (1988) asks whether psychiatry can really be considered an ‘accurate’ science, if it is based on and limited to middle-class, white people from North America, the United Kingdom and Western Europe.
THE PROBLEM OF REDUCTIONISM
The medical paradigm has been criticized for not taking one’s context and culture into account. It is not seen as a holistic model. Examples of this can be seen in the
anti-reductionist argument that there are at least some psychological phenomena that cannot be reduced to biological phenomena – as in the case, for example, of ‘deprivation dwarfism’ (Rosehan & Seligman, 1989).
The American Psychiatric Association (1994) admits within the DSM-IV, that the medical paradigm is reductionistic. The researchers note that “… the term mental disorder
unfortunately implies a distinction between ‘mental disorders and ‘physical’ disorders that is a reductionistic anachronism of mind/body dualism.” They note that this position is not entirely satisfactory and comment that there is usually a ‘physical’ element in ‘mental’ disorders and a ‘mental’ element in ‘physical’ disorders” (American Psychiatric Association, 1994, p.xxi).
THE PROBLEM OF CULTURAL SPECIFICITY
The problem of reductionism within the medical model leads on to a problem with cultural specificity. According to the relativists, the psychiatric diagnostic system is reductionistic and reflects an ethnocentric, Western, white, urban, middle – and upper- class cultural
orientation. As such, it is seen as having limited relevance in other cultural contexts (Lewis – Fernandez & Kleinman, 1994; Marsella, 1979).
The pancultural view of psychological disorders however, argue that the criteria of mental illness around the globe are very much the same and that basic standards of normality and abnormality are universal across all cultures (Frances, First, Widiger, Miele, Tilly, Davis & Pincus, 1991; Murphy, 1976). They base this on research that suggests that there is considerable continuity across cultures in terms of what is considered abnormal behaviour (Butcher, Narikiyo & Vitousek, 1993). For example ‘delusions’, according to Brislin (1993) are seen as a common symptom of schizophrenia in all cultures, but the specific
content of the delusions that people report are seen to be tied to their cultural heritage (Brislin, 1993).
Many critics argue however, that to ignore the concept of culture, renders the medical model inaccurate. Critics point out that judgments of abnormality are influenced to some extent by cultural norms and values (Lewis–Fernandes & Kleinman, 1994).
A clear example of this can be seen in the fact that before 1973, homosexuality was listed as a sexual disorder in the American Psychiatric Association’s diagnostic system (Rothblum, Solomon & Albee, 1986). Nowadays however, homosexuality is no longer considered a disorder, as society has become more accepting of the notion. As can be seen here, cultural opinion has affected the definition of what the medical model terms a mental disorder.
Kleinman (1988) expands the argument that culture should not be ignored, as it plays a large part in influencing our perceptions and treatment of mental illness. Psychiatry according to Kleinman (1988) was overtaken in the 1980’s with a fervor for biological explanations. He maintains that although research has thus far failed to identify and map a unique path physiology for each of the psychiatric disorders, enough progress has been made on the physiological correlates of major depression, panic disorder, and schizophrenia to justify the study of the dominant paradigm - the medical model (Kleinman, 1988).
Kleinman, himself a psychiatrist, points out however, that research also discloses that more is involved in the causal web of psychiatric disorders than changes in neurotransmitters and endocrinological activity. Epidemiological research has begun to point to social contributions to vulnerability for mental illness, through the study of factors such as life events that are perceived as stressful, inadequate social support, the social origins of helplessness and a negative sense of self. Family circumstances are also known to have an effect on mental disorder (Kleinman, 1988).
“....unemployment, poverty, and powerlessness continue to show a statistical association with higher rates for most mental disorders. Thus, socia l psychological aspects of illness and treatment have also been shown to be of considerable significance” (Kleinman, 1988, p.2).
The research thus seems to indicate that in the study of mental ‘illness’, one’s context and culture should not be ignored. Studies indicate that symptomatology in mental ‘illness’ points to the fact that there are “certain significant similarities and many very significant differences” across cultures (Kleinman, 1988, p.45).
Kleinman quotes many sources to demonstrate convincingly that “concepts of emotions, self and body, general illness categories differ so significantly in different cultures that it can be said that each culture’s beliefs about normal and abnormal behavior are distinctive”
(Kleinman, 1988, p.49). He quotes To wnsend (1978) for example, who showed that even within the West, the beliefs of Germans and North Americans about major mental disorder are so fundamentally divergent in each of the societies, that German patients and
psychiatrists held more similar views than did German and North American psychiatrists” (Townsend, 1978 in Kleinman, 1988).
Studies in America suggest that American minority groups generally underutilize therapeutic services (Mays & Albee, 1992). A variety of reasons for this have been stated. ‘Barriers’ appear to contribute to this problem, including cultural barriers. In times of distress, certain cultural groups are reluctant to turn to formal, professional sources for assistance. They tend to prefer informal sources of help, such as cons ulting their families, clergy, elders and sometimes herbalists, or others who share their cultural heritage. Minority groups tend to be distrustful of large, foreign institutions (Checking, 1991; Mays & Albee, 1992; Sue, Zane & Young, 1994).
A major problem that has been noted is that the therapists employed in the institutions do not provide culturally responsive forms of treatment and hence they are not turned to for support. The therapists are almost exclusively white, middle-class people who are not familiar with the unique characteristics of various ethnic groups (Sue & Zane, 1987). As
such, this cultural gap often leads to misunderstandings and poorly planned treatment strategies (Hughes, 1993).
The American Psychiatric Association (1994) acknowledges that the medical model is limited in certain respects and cautions clinicians to be aware of these limitations. It also notes that “…special efforts have been made in the preparation of DSM-IV to incorporate an awareness that the manual is used in cult urally diverse populations” (American
Psychiatric Association, 1994, p.xxiv). Also, it is stated that “a clinician who is unfamiliar of the nuances of an individual cultural frame of reference may incorrectly judge as
psychopathology those normal variations of behavior, belief, or experience that are particular to the individual’s culture” (American Psychiatric Association, 1994, p.xxiv).
The American Psychiatric Association also states in the DSM-IV that the wide international acceptance of the manual suggests it is a useful guide in describing mental disorders as they are experienced by individuals throughout the world. Nonetheless, it is pointed out that evidence suggests that the symptoms and course of a number of DSM-IV disorders, are specifically influenced by cultural and ethnic factors and that one needs to take this into account (American Psychiatric Association, 1994, p.xxiv).
THE PROBLEM OF ‘EMOTIONAL DISTANCE’
“It’s a pain that no one really knows unless they’ve been there. It’s too abstract to even describe. If you even describe it....it’s not the worst ever and it’s not as bad as cancer... it’s just on another level. I don’t even know how to explain it to you. It’s on such a level of not being able to come anywhere near your fellow human being. You don’t even feel human at times...you feel that you can’t connect. It’s a strange feeling...it’s depersonalising, dehumanising it’s a very peculiar thing.... and the whole thing about it, is that you don’t know how you should feel...you don’t know how you should feel. That’s the bloody trouble with it”. Christa – research participant.
Dorothy Rowe, in Breggin (1993) comments that some psychiatrists, when confronted with the messiness, pain and fear of human experience, discover that they can deal with this messiness and pain by simply denying that it exists. In due course, they become ‘objective scientists’, or in the now fashionable term, ‘biopsychiatrists’. “Human suffering, they say, is nothing but aberrant biochemistry” (Rowe in Breggin, 1993, p.xxiii).
Hinshelwood (1999) describes the ‘scientific attitude’ as a type of defense mechanism. When people feel helpless and threatened, the author explains, they retreat into what is known or familiar. In the case of a ‘difficult’ patient, the psychiatrist tends to feel more ‘in control’ or empowered, when he or she retreats into their scientific stance, divorcing him or herself from the unpleasant emotions he or she might be experiencing regarding his or her patient. (Hinshelwood, 1999).
Breggin maintains that Psychiatry has set the tone and direction for the field of mental health and has been quickly pushing it towards a more biological or medical viewpoint (Breggin, 1993). “What does it say about professionals who argue that their patients are so different from themselves?”, he asks. Biopsychiatry, Breggin posits, holds that patients are so different from other ‘normal’ humans, that almost anything can be done to them, including surgical and electrical procedures. Biopsychiatry does not assume that those seeking help possess the same human sensitivities as anyone else, including the therapist (Breggin, 1993, p.76).
“Biopsychiatrists dare not look their patients in the eye, for fear of seeing the psychological truth; they cannot look into their patients hearts for fear of empathizing with them. Ultimately they must deny their own feelings in order to deny the feelings of others” (Breggin, 1993, p.226). In order to treat a depressed person as a biochemical defective mechanism, many biopsychiatrists, comments Breggin, approach the patient with an especially dehumanizing view (Breggin, 1993).
He maintains that during his training as a psychiatrist, he learned that love and care, and supporting the patient's self-determination, were the most effective elements in helping
people, yet he was taught that patients had diseases, like Schizophrenia or Bipolar Mood Disorder. He was taught that they needed pills instead of people and shock therapy instead of social reform (Breggin, 1993, p.11). He feels that the majority of psychiatrists are not trained in - and have no interest in - ‘talking therapy’. His or her entire training and commitment is more likely to be focused on ‘medical diagnosis’ and ‘physical treatment’. “He or she may look at you with all the empathy and understanding of a pathologist staring through a microscope at germs, and then offer you a drug” (Breggin, 1993, p.12).
Foudraine (1974) mirrors Breggin’s theory that patients need to be related to as people and not diseases. He learnt in his many years of experience as a psychiatrist, that it was not useful to believe in a ‘disease’ or a mysterious ‘physical process’, but that it was more healing to try and forget the labels and bring about at least a mutual interpersonal relationship with the ‘patient’. In a relationship, - even with someone who is suffering from psychosis - more and more of the client’s struggle becomes intelligible and as this is reflected to the patient, so the patient heals (Foudraine, 1974, p.11).
There should be no investigator here, says Foudraine (1974), but a fellow human being.
B. THE PROBLEM OF LANGUAGE AND LABELS
THE LANGUAGE OF PATHOLOGY
Psychiatric language has a “…utility as a common language for communication” (American Psychiatric Association, 1994, p. xxiii).
Foudraine (1974) speaks of his experience in various psychiatric institutions. He comments that he was always amazed at how completely the ‘medical patient’ role had taken control of the identity of those around him. He maintains that whenever patients seemed unable to face their problems and conflicts, they described their experiences in medical terms (Foudraine, 1974).
Foudraine began to counteract this medical conceptualisation. He started to change the medical language in the institutions in which he was employed. The hospital became a ‘school for living’, the doctor became an ‘educator,’ and the patient ‘a student’. He tried to encourage conceptualizations of patients as not being ill, but rather, as being “ignorant about themselves and the forming of relationships with others” (Foudraine, 1974, p.299).
Although Foudraine’s chosen labels might be considered slightly patronizing to a certain extent, he raises an important observation about the language we choose to use in the mental health setting. By and large, the language employed appears to be the language of
pathology. Foudraine (1974) comments that the language of pathology is hardly noticed anymore “… because this whole medical culture and language have become so much the background to our work that it is like air, whose absence we only notice when we are choking” (Foudraine, 1974, p. 312).
Foudraine, it seems, was attempting to disencumber the environment of its ‘medical
mythology’ (Foudraine, 1974, p.308), yet as can be expected, he, was not very successful. Foudraine explains this in terms of the ‘naming prerogative’. Artiss (in Foudraine, 1974) explains that the right to name things - to define language forms - is the right of the group and the culture and not the right of the ind ividual.
Foudraine (1974) maintains that as ‘symbolic animals’ we are always making word-maps of the world. He explains that we take over these maps from one another. Not every map is always a good one – something we notice as we use them on the course of a journey. A good map will take us to the right destination and to stay on course we should only have to glance occasionally at the landscape.
Thus Anatol Rapoport (1970) comments that language is a representation of the world we live in. According to him there is but one human activity that compels us to keep on
improving the map so that it will correspond better with the world landscape. This activity is scientific activity (Rapoport, 1970). Foudraine (1974) speaks of ‘semantic maps’, or a
screen of words (symbols) that stands between us and the world. From time to time, he notes, there are certain people who try to look behind the screen (Foudraine, 1974).
It is certainly fair, as Foudraine (1974) notes, to look behind the screen of the medical model and check whether the language of medicine is sufficiently suited to the field of human action and behaviour. We may well inquire whether or not this particular world -map does not make us keep losing our way (Foudraine, 1974).
Szasz (1961) seems to have led the field in raising the problem of medical conceptualizing in psychiatry. He holds that while the notion of ‘mental illness’ had a historical justification during the nineteenth century, in the twentieth it has no scientific value. Szasz (1961) defines psychiatry as a pseudo-medical specialty and attempts to logically demolish its medical edifice. In its position, he places a ‘theory of personal conduct.’ He bases this theory on the productive hypotheses derived from the social sciences - psychoanalysis, sociology, social psychology, communication theory - which he claims have given us a knowledge of people, rather than diseases (Szasz, 1961).
Szasz (1961), sites Karl Popper, in stating that science starts with hypotheses, which later become myths. A hypothesis is a provisional way of representing reality. We must be bold enough to criticize these myths if, instead of clarifying a situation, they obscure it and block new ways of formulating the issues (Szasz, 1961).
Szasz (1961) maintains that psychiatry, as a model, is in tune with certain myths that obscure ‘reality’. In Szasz’s perception, the linguistic apparatus of medical-biological-science has prevented psychiatry from growing into a component part of social science. According to Szasz (in Soderlund, 2001), psychiatry is stuck in an out-of-date thought model.
Sarbin (1969) writes along similar lines to Szasz. He argues that certain ways of thinking have become ‘myths’. Sarbin (1969) claims that the ‘myth of mental illness’ has given doctors the power and the obligation to assess and to pass judgment on people with problems in living. Sarbin examines the history of this ‘figure of speech’ and the social
consequences it has endured. He explains that a semantic analysis of the situation could be very meaningful. ‘He has problems in living’, he notes, has a dramatically different effect from “He is a psychiatric patient with a mental illness” (Sarbin, 1969).
Sarbin (1969) comments on the history of the language of pathology by explaining the story of Teresa of Avila. She introduced the notion ‘as if sick’ in order to save fellow nuns who were behaving strangely from the fate of being burned by the inquisition. Sarbin maintains that this metaphor is no longer useful now and that it is time to put it to rest. In order to do this, however, we will have to put forward an alternative (Sarbin, 1969). Sarbin maintains that we need new words if we are to reach out into the community and help those people who lead lives of quiet desperation, some of whom occasionally break out of their ‘social entrapment’ with bizarre conduct (Sarbin, 1969).
THE LANGUAGE OF PATHOLOGY AND LABELING
“They had a special language: regression, acting out, hostility, withdrawal, indulging in behaviour. This last phrase could be attached to any activity and make it sound suspicious: indulging in eating behaviour. In the outside world people ate and talked and wrote, but nothing we did was simple”.
Girl, Interrupted, by Susanna Kaysen (1993, p.15)
Andersen (1996) argues, that language is not innocent. The medical model, as has become evident, tends to use certain language to label people. Its most predominant label seems to be the label of ‘patient’. This label tends to encourage people with problems to adopt this role – that is, a passive role in which the person is not empowered to help themselves. According to research, this apparently undermines the likelihood of improvement in the long run (Davison & Neale, 1986; Korchin, 1976).
The medical model has been criticized by critics specifically as it also tends to allocate derogatory labels to individuals. These labels carry a social stigma, which undoubtedly
creates additional distress (Szasz, in Soderlund, 2001). Attempts to document the negative effects of labeling have rendered mixed results (Segal, 1978), but generally the tendency to generalize inappropriately from the label, does occur (Barlow & Durrand, 1995).
Labels are known to create self – fulfilling prophecies, where sufferers proceed to act-out the roles created for them. (Becker, 1973; Rothblum, Solomon & Albee, 1986).
The medical model has been criticized by Thomas Szasz (clearly it’s most vociferous critic), as being unrealistic. Szasz (in Soderlund, 2001) states that mental symptoms cannot be compared to physical illness symptoms, as the two are entirely different in nature. Szasz also argues that abnormal behaviour is not an illness, but a problem in living and that under the guise of ‘healing the sick’, society is allowed to lock away deviant people, in order to enforce conformity. (Sahakian et al., 1986). As Szasz maintains, “…there is, strictly speaking, no such thing as ‘mental illness’ (Szasz in Soderlund, 2001, p.8). Szasz believes tha
