The disease concept towards abnormality and where it goes wrong.

The psychiatry and anti psychiatry debate has been going on for decades. The pressures from drug companies and insurance companies on the medical profession to have exact classifications of diagnosis resulted in the formulation of the Diagnostic and Statistical Manual (DSM). Emil Kraeplin (1856-1926) was involved in the first publication of the DSM and is responsible for the disease theory towards mental illness. The fact that the classifications and list of disorders has expanded with each new edition is a cause for distress. From 107 different psychopathological conditions in 1952 to 365 in 1994, the next edition could be a greater cause for concern.  This paper will discuss the concept of mental illness as a disease paying particular reference to the writings of Thomas Szasz (2005) and his issues with the orthodox medical approach to mental health. Another leading figure in this controversy is Jeremy Bentall (2009) who famously stated that happiness could be classified as a psychiatric disorder. The fact that it resulted in reckless or irrational behaviour and was associated with irregular activity in the cerebral hemisphere were the first points made and also the fact that people vary in their genetic predisposition to it further entitled it to psychiatric classification. Apart from this Bentall (2009) has made considerable progress in the mental health fields, suggesting changes therapists need to make in an attempt to right the wrongs currently being committed. This fact highlights the errors with the diagnostic criteria currently in use and this paper will discuss the errors highlighted by these two leading figures.

In “idiots, infants and the insane: mental illness and incompetence” Szasz (2005) gives a historical account of societies treatment of abnormal behaviour which resulted in those individuals being committed to an institution. He highlights that voluntary referral was unheard of in those times.  It was only after concentration camps were highlighted through World War 2 and were seen to mirror mental institutions that changes were made to the policies for admission.  Occurring at the same time was the discovery of drug therapy for mental illness. The belief that mental disorders paralleled diseases of the brain or chemical imbalances were accepted socially and this lead to out-patients treatment programs. The world became accustomed the concept of normality around mental illness within society and the belief that drug therapy would be effective in curing the disorder was taken on by most people. Szasz (2005) highlights the social and material benefits that were received by drug companies and insurance companies once this form of therapy was accepted and this belief in the disease theory to mental health. 

This belief that mental disorders belong in the category of a disease is an issue for Szasz (2005). He states that a disease is something you have while abnormal behaviours are something one does. The disorder may mirror some of the symptoms of a disease i.e. pain and deterioration but this does not constitute a disease. For a disease to be categorised as a disease it must first be capable of scientific testing, of measuring and of examination. It must be evident at a cellular or molecular level and must also be evident on an autopsy table. Szasz (2005) hypothesised that mental disorders are really problems with living and society’s treatment of this as a medical illness offering medical treatment options is not dealing with the root causes.  While his paper highlights his issues with the legal incompetence element attached to mental patients, his point on possibilities for change are interesting. He states that while changes in mental health policies are liberating patients from extreme measures of control, they have failed to increase personal responsibility in the individual and a sense of being accountable for their actions. The method being taken on at present is the expansion of services available to society which serves to further expand and highlight mental illness within our society. According to Szasz (2005) the only solution to this issue is the reduction in the number of individuals being treated with mental illness, but the removal of the belief in mental illness as a disease must occur first. The neo-Kraeplin approach must be revised and or discarded and the emphasis must be focused more onto the methods suggested by Jeremey Bentall (2009).

Bentall (2009) criticises the DSM stating that it creates an illusion of order in the mental health fields. The manual provides people with the notion that drug therapy is an acceptable route to take when encountering a person in mental distress rather than treating or searching out the causes. The fact that this manual is being revised and newer editions are being published sends a message to people that there is scientific evidence that mental health conditions can be distinguished from one another. The fact that two people who are diagnosed as having schizophrenia may not share a single symptom but are yet both classified with this label does not seem logical or scientific. Bentall (2009) advocates for symptom treatment approach to mental health issues. The belief that disorders exist on a continuum is one that is overlooked by Kraeplinian methods.  Bentall (2009) holds the belief that we may be anywhere along the continuum of normal to abnormal and if the person is guided into acceptance of their position then it is possible for them to lead productive lives regardless. He highlights that fear of madness may be the bigger issue in our society, and with the expansion of services highlighted by Szasz (2005) it is not an unreasonable statement.

 Viktor Frankl (1984) created a therapy that focused on personal meaning in one’s life. The element of having a sense of meaning in life has had amazing effects on individuals’ sense of self and mental health. Logotherapy is focused on existential frustrations, or as Szasz (2005) terms it problems with living, and its effectiveness has been proven in various cases from addiction to schizophrenia. The aim is to reduce fear of fear and to give people an opportunity see themselves outside of their diagnosis. This mirrors Bentalls (2009) fear of madness theory and suggests that his advice to therapists to engage more with clients and prescribe less would have greater benefits than continuing with a system that is clearly missing something. 

References:

Bentall. J ( 2009, March 31) Diagnosis are psychiatrys  star signs. Let’s listen more and drug people less. Retrieved on April 8, 2010 from:  http://www.guardian.co.uk/commentisfree/2009/aug/31/psychiatry-psychosis-schizophrenia-drug-treatments.

Frankl, V. E. (1984). Man’s search for meaning. New York: Simon & Schuster.

Szasz. T ( 2004)Idiots, Infants and the insane: Mental illness and legal competence. Journal of Medical Ethics. 31(2) 78-81.

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~ by niamh27 on April 8, 2010.

3 Responses to “The disease concept towards abnormality and where it goes wrong.”

  1. In your opening comments you refer to the pressure drug and insurance companies put on psychologists to have precise classifications of diagnosis. As you mention it raises concerns and causes distress as this pressure led to the production of the original DSM. If this point is true and to further your point, then it has serious implications with regard to the ethics that psychology adheres to. The ethics code of the Psychological Society of Ireland states that psychologists should avoid entering into contracts that go against the code and speak out if such issues arise (PSI, 2003). If the DSM was not going to be produced without the pressure of the companies then surely it should not have been produced due to this pressure. It appears as a case of dual allegiance in which psychology lost. If all this is the case then it is astonishing that clinical psychology still bases itself on this unethical framework. Therefore, your assertions that clinicians should engage more with clients and prescribe less certainly seem more valid than continuing with a system that is fundamentally flawed.

  2. Something that came across quite strongly in your article is that psychologists are frustrated with what is in their opinion the inadequacy of the DSM (e.g. Szasz, 2005, Bentall 2009). If there are such recognised faults in the DSM, I don’t understand we have not seen an alternative to date, or even significant, satisfying improvements from one version of the DSM to the next. Granted, the DSM has its plus side, and I think that one benefit of its meticulous diagnostic criteria is that it has helped eliminate some of society’s ignorance surrounding the issue of mental health in that we no longer can label people as just ‘mad’ or ‘nuts’. But maybe it has outlived its usefulness. For example, Maddux(2005) claims that the DSM remains a primary barrier for the movement of positive psychology, as it built on a foundation of an illness ideology-the antithesis to the goals and principles of positive psychology. I think that maybe it is time for clinical psychologists to be more proactive regarding their criticisms of the DSM, they should be co-operating in the deconstruction of the DSM rather then individually ranting and raving about its flaws.

    Reference:
    Maddux., J.E. (2005) Stopping the ‘Madness’: Positive Psychology and the Deconstruction of the Illness Ideology and the DSM. In Snyder, C.R., & Lopez, S.J. (Eds) Handbook of Positive Psychology. New York: Oxford University Press.

  3. I would comment that many mental disorders have been found to have underlying biological causes, for example, schizophrenia is associated with reduced brain tissue, abnormal brain development, and excessive dopamine, and the theory that this is a result of a genetic vulnerability interacting with a maternal acquisition of influenza virus during pregnancy has received good support (Carlson, 2008). As such schizophrenia would meet the criteria you provide for a disease, being evident at a cellular level and on an autopsy table. Therefore if the cause is biological then drug therapy is an appropriate intervention, and I would argue that in contrast to Szasz (2005), to refrain from medical treatments would be to neglect to treat the root causes, not the other way around.

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