162
A THEORETICAL PERSPECTIVE ON SOCIAL PSYCHIATRY
by JOSHUA BIERER and
JOHN D. WILLIAMSON the centuries, medical thinkers tried apply emotional disorders THROUGH conceptual model physical illness-the classified, hidden
to mental and medical model. cases sought, treatments developed and4 Syndromes have been in the belief that &dquo;madness is just another disease we prognostications attempted, don’t fully understand ... yet&dquo; (Siegler and Osmond, 1974). In developing such a view, physicians have had to compete with folk concepts of witchcraft, 4 personification of evil and deterministic philosophies which view human behaviour as manifestly purposeful. In the main, they have been successful; madness and the myriad of emotional and existential disorders are widely believed to be diseases. And yet, many physicians are confused about the reasoning behind the psychia- ~ trist’s selection of &dquo;relevant&dquo; clinical data, his formulation of the case and his choice of treatment. In this short essay we shall look at some of the difficulties with conventional methods of psychiatric practice. , Use of the Medical Model implies a belief in the concept of normality, and, more specifically, in the concepts of physiological normality. Those who practise thisI type of psychiatry see nothing wrong in making the philosophical and political leap I from the idea of physiological homeostasis (or equilibrium) to that of J acceptable mentation or behaviour. Similarly, nothing threatening is seen in the j! statement that &dquo;normal behaviour must be generated by normal experience&dquo; despite its obvious moral, or at least social value-laden, overtones. Such practitioners see Medicine in terms of a &dquo;good institution aimed at human betterment&dquo;. The moral and political implications of that aim are rarely acknowledged, except when thei social background of a service conflicts with the commentator’s own, as is shown by the outcry against the psychiatrisation of dissidents in the Soviet Union. Open debate may benefit from an examination of some of the difficulties with this approach to psychiatry. The difficulties of attempting a classification of psychiatric abnormalities that may be used have already been hinted at. Clearly, if psychiatric abnormalities were part of a normal-abnormal dichotomy, as the protagonists of the Medical Model would have us believe, and if this dichotomy were ~ objective, then cultural differences should be minimal. although &dquo;schizophrenia&dquo; tends to be viewed similarly throughout the world, no true international consensus has emerged in this area. That this divergence is not the result of a ,, particular form of political ideology is evidenced by the World Health Organisation’s findings that the two countries with the &dquo;loosest&dquo; definition of the schizophrenic syndrome are the Soviet Union and the United States. Again, if a dichotomy between normal and abnormal existed, we should ask ’ ourselves why it has not been possible to develop psychometric tests that would identify the two groups with any degree of consistency. As shown in a paper in the present volume of this journal (Williamson et al., 1976), few of the many tests
have
a
to
of
religious
socially j
Yet,
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
163 able to agree on a particular subject’s classification at all. Usually the remains the final arbiter. Thus we have experienced a massive shift in the notion of psychiatric screening. No longer are &dquo;abnormals&dquo; being sought, but instead we concentrate on finding groups the members of which a psychiatrist would in all probability diagnose as &dquo;cases&dquo;. Conventional psychiatry is seen for what it is: a subjective response to a social situation that is labelled as unsatisfactory to and by some individual who may or may not be presented as the &dquo;case&dquo;. In short, psychiatry may be in danger of becoming an instrument of social control rather than a mechanism by which distressed persons can be helped to resolve their difficulties. available
are
psychiatrist
The classical approach to this dilemma has been to seek alternative models not based on such a dichotomy. Such continuous conceptual models hinge on a belief that unseen, although potentially understandable, forces control the lives of us all. Over the past 40 years or so, three major models have developed, with a few hybrids. Until the Second World War, the only serious challenge to conventional psychiatry was psychoanalysis. Despite its popular appeal, it was treated with considerable reserve by some sections of the medical profession. &dquo;Poor people ... much prefer the familiar and easily understood medical model. They have never shown much enthusiasm for the classbased psychoanalytic model and its derivatives. It is true that they seldom had much access to it, but they do not seem to believe themselves deprived for lack of it; what they want is what they consider to be the best medical treatment available.&dquo; (Siegler and Osmond, 1974) Despite such critical comment from medical sources, psychoanalysis and the later developments of family interaction theories continue to be discussed widely and seriously. The various theories associated with psychoanalysis all share certain characteristics: that a developmental impasse, early deprivation, distortions in early interpersonal relationships and confused communications between parent and child may lead to adult vulnerability in certain situations. After the Second World War, a growing concern with the patient’s social context emerged, over and above the individual characteristics of interest to psychoanalysts. In the 1950s much attention was paid to the hospital milieu, while in the 1960s attention shifted to the community outside the institution. The social view was concerned with the way in which the individual functions in the social situation, and symptoms were regarded as an index of social dysfunction. The medical profession at large was not notably happier with this approach than with psychoanalysis: &dquo;There is now evidence that many thousands of these patients, i.e. those returned to their own community from the artificial social environment of the hospital, are drifting into jails, flophouses, rundown hotels, utter seclusion in single rooms and, perhaps most questionably, private madhouses run in their off-time by the staff of those mental hospitals from which the patients have been extruded.&dquo; (Siegler and Osmond, 1974) The Social Model has been variously attacked because it is allegedly too radical or too conservative (for example by those who hold rapid social change or progress responsible for mental problems). One radical social psychiatry unit experimenting with community care for socially disturbed people failed miserably when local psychiatrists dumped on it chronic and institutionalised patients, while the local police &dquo;proved recalcitrant&dquo;. Medicine has a long and melancholy tradition of opposing alternatives to established practice, even if it is the patient who loses out.
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
164 At the time the Social Model emerged, the field was further confused by the work of the Behavioural Psychologists. They hold that all mental diseases are instances of abnormal behaviour that has been learnt as a result of aversive events and is maintained either because it leads to positive effects or avoids deleterious ones. The past 20 years have seen constant debate and controversy about which of these models is &dquo;right&dquo; and which &dquo;wrong&dquo;. Protagonists of one model unhelpfully tend to reject the work of proponents of another as pursuing &dquo;non-psychiatric problems&dquo;. Such is the danger of model-building. As Thomas Kuhn has stated: &dquo;The man who premises a paradigm model when arguing its defence can nonetheless provide a clear exhibit of what scientific practice will be like for those who adopt the new view of nature. That exhibit can be immensely persuasive, often compellingly so. Yet, whatever its force, the status of the circular argument is only that of persuasion. It can not be made logically or even probabilistically compelling for those who refuse to step into the aisle.&dquo;
(Kuhn, 1962) in no position to say that any one view of mental, emotional or existential problems is the correct one. We are therefore subject to the emotional persuasion postulated by Kuhn. Yet there are ways in which the various camps might be brought closer together. If protagonists of one model would only attempt to see their own case-load in terms of their antagonist’s models, or if they would read their competitor’s descriptions of their work in terms of their own preferred model, the whole of psychiatry might reach a state of open-mindedness and eclecticism that would aid future research. A good example of what we are saying is provided by Lazare (1973) who obtained a history of a single depressed patient from the standpoint of the four maj ~r models: We
are
_
_
°
Medical Model A widow gave a history of a depressive syndrome. During the past few months she had lost nine kg in weight, had early morning awakening, and had a diurnal variation in mood manifested by feeling better as the day went on. She described herself as feeling hopeless, helpless and worthless. There was some retardation of speech. She denied suicidal intent and presented no evidence of delusions or paranoid ideation. Twenty-three years previously a similar episode of depression had remitted spontaneously. The patient had a sister who was hospitalised for a depressive illness that responded positively to ECT.
Psychological Model A widow had been depressed for a few months after the death of her husband. Although the marriage seemed happy at times, there were many stormy periods in their relationship. There had been no visible signs of grief since his death. Since the funeral, she had been depressed and had lost interest in her surroundings. For no apparent reason she blamed herself for minor events of the past. Sometimes she criticised herself for traits that characterised her husband more than herself. She had had a similar reaction to the death of her mother 23 years previously, when she and her mother had lived together. From the family history, it could be inferred that the relationship was characterised by hostile dependence. Six months after her mother’s death, the patient married. She seemed intelligent and motivated
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
165 for treatment, and had considered psychoanalysis and gain a better understanding of herself.
therapy in
the past
to
Behavioural Model A widow gave a
history of depressive behaviours of anorexia, insomnia, hopelessness, helplessness and worthlessness. These behaviours started shortly after the death of her husband. Throughout the marriage, he had been a continuous source of reinforcement to the patient. This quality feelings
of
of the husband’s interaction with his wife had been evident since the marriage, at a time when the patient was still depressed after her mother’s death. The family stated that the husband had always ignored the patient’s demands and pleas of helplessness while responding actively to the more positive sides of her personality. After his death, she began to complain to her children about her loss of appetite and her sense of helplessness. They responded to these complaints with frequent visits and telephone calls but the depressive behaviour only worsened. Social Model A widow had been depressed during the past few months since the death of hesr husband. He had been the major figure in her life, and his loss has left her feeling lonely and isolated. After his death, she moved to a small apartment, which was some distance from her old neighbourhood. Although she was satisfied with her new quarters, she found the community strange. Furthermore, she did not have access to public transportation, which would have enabled her to visit her old friends, children and grandchildren. Since the death of her husband, old strains between the patient and her children had been aggravated.
protagonists of these very different approaches be brought together? Yet closer relationship is established, it will obviously be difficult to share relevant experiences and improve the therapeutic performance. The lack of a consensus as to what constitutes a psychiatric problem or how such a problem should be dealt with has led some critics to complain that psychiatry is unscientific. It resists generalisation, they say; and when one cannot generalise, it becomes almost impossible to develop a scientific theory. Hence the model-building exercises. The difficulties have not been overcome, only redefined in terms of competing models. Somewhat perversely, Joshua Bierer has argued that not only is psychiatry a science, but that it is the most exact of sciences. It is a science in that there is a cause and an effect which may be varied by intervention. The semantic jiggerpokery of the use of the word &dquo;exact&dquo; is simply to emphasise the fact that there are many levels of generalisation; if a &dquo;cure&dquo; is exactly &dquo;right&dquo; for a given patient, it should be conceptually &dquo;right&dquo; for another patient with relevant similarities. Thus we have come full circle. We do not start with a theoretical perspective and evaluate the necessary therapies, rather we devise individually tailored therapies, seeking to generalise and construct a theory at a later stage. To do this, models should, and must, be mixed so that the entire picture of the patient and the problem is available to the therapist. This is the theme of Social Psychiatry.
How until
can
a
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
166 REFERENCES
Kuhn, T. C. (1962): The Structure of Scientific Revolution; Chicago. Lazare, A. (1973): New Engl. J. Med. 288 (No. 7), 345. Siegler, M., and Osmond, H. (1974): Models of Madness, Models of Medicine; New York; Macmillan.
Williamson, J. D., Robinson, D., and Rowson, S. (1976) in Page No. 162
the
current
volume of this
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
Journal,
A THEORETICAL PERSPECTIVE ON SOCIAL PSYCHIATRY
by JOSHUA BIERER and
JOHN D. WILLIAMSON the centuries, medical thinkers tried apply emotional disorders THROUGH conceptual model physical illness-the classified, hidden
to mental and medical model. cases sought, treatments developed and4 Syndromes have been in the belief that &dquo;madness is just another disease we prognostications attempted, don’t fully understand ... yet&dquo; (Siegler and Osmond, 1974). In developing such a view, physicians have had to compete with folk concepts of witchcraft, 4 personification of evil and deterministic philosophies which view human behaviour as manifestly purposeful. In the main, they have been successful; madness and the myriad of emotional and existential disorders are widely believed to be diseases. And yet, many physicians are confused about the reasoning behind the psychia- ~ trist’s selection of &dquo;relevant&dquo; clinical data, his formulation of the case and his choice of treatment. In this short essay we shall look at some of the difficulties with conventional methods of psychiatric practice. , Use of the Medical Model implies a belief in the concept of normality, and, more specifically, in the concepts of physiological normality. Those who practise thisI type of psychiatry see nothing wrong in making the philosophical and political leap I from the idea of physiological homeostasis (or equilibrium) to that of J acceptable mentation or behaviour. Similarly, nothing threatening is seen in the j! statement that &dquo;normal behaviour must be generated by normal experience&dquo; despite its obvious moral, or at least social value-laden, overtones. Such practitioners see Medicine in terms of a &dquo;good institution aimed at human betterment&dquo;. The moral and political implications of that aim are rarely acknowledged, except when thei social background of a service conflicts with the commentator’s own, as is shown by the outcry against the psychiatrisation of dissidents in the Soviet Union. Open debate may benefit from an examination of some of the difficulties with this approach to psychiatry. The difficulties of attempting a classification of psychiatric abnormalities that may be used have already been hinted at. Clearly, if psychiatric abnormalities were part of a normal-abnormal dichotomy, as the protagonists of the Medical Model would have us believe, and if this dichotomy were ~ objective, then cultural differences should be minimal. although &dquo;schizophrenia&dquo; tends to be viewed similarly throughout the world, no true international consensus has emerged in this area. That this divergence is not the result of a ,, particular form of political ideology is evidenced by the World Health Organisation’s findings that the two countries with the &dquo;loosest&dquo; definition of the schizophrenic syndrome are the Soviet Union and the United States. Again, if a dichotomy between normal and abnormal existed, we should ask ’ ourselves why it has not been possible to develop psychometric tests that would identify the two groups with any degree of consistency. As shown in a paper in the present volume of this journal (Williamson et al., 1976), few of the many tests
have
a
to
of
religious
socially j
Yet,
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
163 able to agree on a particular subject’s classification at all. Usually the remains the final arbiter. Thus we have experienced a massive shift in the notion of psychiatric screening. No longer are &dquo;abnormals&dquo; being sought, but instead we concentrate on finding groups the members of which a psychiatrist would in all probability diagnose as &dquo;cases&dquo;. Conventional psychiatry is seen for what it is: a subjective response to a social situation that is labelled as unsatisfactory to and by some individual who may or may not be presented as the &dquo;case&dquo;. In short, psychiatry may be in danger of becoming an instrument of social control rather than a mechanism by which distressed persons can be helped to resolve their difficulties. available
are
psychiatrist
The classical approach to this dilemma has been to seek alternative models not based on such a dichotomy. Such continuous conceptual models hinge on a belief that unseen, although potentially understandable, forces control the lives of us all. Over the past 40 years or so, three major models have developed, with a few hybrids. Until the Second World War, the only serious challenge to conventional psychiatry was psychoanalysis. Despite its popular appeal, it was treated with considerable reserve by some sections of the medical profession. &dquo;Poor people ... much prefer the familiar and easily understood medical model. They have never shown much enthusiasm for the classbased psychoanalytic model and its derivatives. It is true that they seldom had much access to it, but they do not seem to believe themselves deprived for lack of it; what they want is what they consider to be the best medical treatment available.&dquo; (Siegler and Osmond, 1974) Despite such critical comment from medical sources, psychoanalysis and the later developments of family interaction theories continue to be discussed widely and seriously. The various theories associated with psychoanalysis all share certain characteristics: that a developmental impasse, early deprivation, distortions in early interpersonal relationships and confused communications between parent and child may lead to adult vulnerability in certain situations. After the Second World War, a growing concern with the patient’s social context emerged, over and above the individual characteristics of interest to psychoanalysts. In the 1950s much attention was paid to the hospital milieu, while in the 1960s attention shifted to the community outside the institution. The social view was concerned with the way in which the individual functions in the social situation, and symptoms were regarded as an index of social dysfunction. The medical profession at large was not notably happier with this approach than with psychoanalysis: &dquo;There is now evidence that many thousands of these patients, i.e. those returned to their own community from the artificial social environment of the hospital, are drifting into jails, flophouses, rundown hotels, utter seclusion in single rooms and, perhaps most questionably, private madhouses run in their off-time by the staff of those mental hospitals from which the patients have been extruded.&dquo; (Siegler and Osmond, 1974) The Social Model has been variously attacked because it is allegedly too radical or too conservative (for example by those who hold rapid social change or progress responsible for mental problems). One radical social psychiatry unit experimenting with community care for socially disturbed people failed miserably when local psychiatrists dumped on it chronic and institutionalised patients, while the local police &dquo;proved recalcitrant&dquo;. Medicine has a long and melancholy tradition of opposing alternatives to established practice, even if it is the patient who loses out.
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
164 At the time the Social Model emerged, the field was further confused by the work of the Behavioural Psychologists. They hold that all mental diseases are instances of abnormal behaviour that has been learnt as a result of aversive events and is maintained either because it leads to positive effects or avoids deleterious ones. The past 20 years have seen constant debate and controversy about which of these models is &dquo;right&dquo; and which &dquo;wrong&dquo;. Protagonists of one model unhelpfully tend to reject the work of proponents of another as pursuing &dquo;non-psychiatric problems&dquo;. Such is the danger of model-building. As Thomas Kuhn has stated: &dquo;The man who premises a paradigm model when arguing its defence can nonetheless provide a clear exhibit of what scientific practice will be like for those who adopt the new view of nature. That exhibit can be immensely persuasive, often compellingly so. Yet, whatever its force, the status of the circular argument is only that of persuasion. It can not be made logically or even probabilistically compelling for those who refuse to step into the aisle.&dquo;
(Kuhn, 1962) in no position to say that any one view of mental, emotional or existential problems is the correct one. We are therefore subject to the emotional persuasion postulated by Kuhn. Yet there are ways in which the various camps might be brought closer together. If protagonists of one model would only attempt to see their own case-load in terms of their antagonist’s models, or if they would read their competitor’s descriptions of their work in terms of their own preferred model, the whole of psychiatry might reach a state of open-mindedness and eclecticism that would aid future research. A good example of what we are saying is provided by Lazare (1973) who obtained a history of a single depressed patient from the standpoint of the four maj ~r models: We
are
_
_
°
Medical Model A widow gave a history of a depressive syndrome. During the past few months she had lost nine kg in weight, had early morning awakening, and had a diurnal variation in mood manifested by feeling better as the day went on. She described herself as feeling hopeless, helpless and worthless. There was some retardation of speech. She denied suicidal intent and presented no evidence of delusions or paranoid ideation. Twenty-three years previously a similar episode of depression had remitted spontaneously. The patient had a sister who was hospitalised for a depressive illness that responded positively to ECT.
Psychological Model A widow had been depressed for a few months after the death of her husband. Although the marriage seemed happy at times, there were many stormy periods in their relationship. There had been no visible signs of grief since his death. Since the funeral, she had been depressed and had lost interest in her surroundings. For no apparent reason she blamed herself for minor events of the past. Sometimes she criticised herself for traits that characterised her husband more than herself. She had had a similar reaction to the death of her mother 23 years previously, when she and her mother had lived together. From the family history, it could be inferred that the relationship was characterised by hostile dependence. Six months after her mother’s death, the patient married. She seemed intelligent and motivated
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
165 for treatment, and had considered psychoanalysis and gain a better understanding of herself.
therapy in
the past
to
Behavioural Model A widow gave a
history of depressive behaviours of anorexia, insomnia, hopelessness, helplessness and worthlessness. These behaviours started shortly after the death of her husband. Throughout the marriage, he had been a continuous source of reinforcement to the patient. This quality feelings
of
of the husband’s interaction with his wife had been evident since the marriage, at a time when the patient was still depressed after her mother’s death. The family stated that the husband had always ignored the patient’s demands and pleas of helplessness while responding actively to the more positive sides of her personality. After his death, she began to complain to her children about her loss of appetite and her sense of helplessness. They responded to these complaints with frequent visits and telephone calls but the depressive behaviour only worsened. Social Model A widow had been depressed during the past few months since the death of hesr husband. He had been the major figure in her life, and his loss has left her feeling lonely and isolated. After his death, she moved to a small apartment, which was some distance from her old neighbourhood. Although she was satisfied with her new quarters, she found the community strange. Furthermore, she did not have access to public transportation, which would have enabled her to visit her old friends, children and grandchildren. Since the death of her husband, old strains between the patient and her children had been aggravated.
protagonists of these very different approaches be brought together? Yet closer relationship is established, it will obviously be difficult to share relevant experiences and improve the therapeutic performance. The lack of a consensus as to what constitutes a psychiatric problem or how such a problem should be dealt with has led some critics to complain that psychiatry is unscientific. It resists generalisation, they say; and when one cannot generalise, it becomes almost impossible to develop a scientific theory. Hence the model-building exercises. The difficulties have not been overcome, only redefined in terms of competing models. Somewhat perversely, Joshua Bierer has argued that not only is psychiatry a science, but that it is the most exact of sciences. It is a science in that there is a cause and an effect which may be varied by intervention. The semantic jiggerpokery of the use of the word &dquo;exact&dquo; is simply to emphasise the fact that there are many levels of generalisation; if a &dquo;cure&dquo; is exactly &dquo;right&dquo; for a given patient, it should be conceptually &dquo;right&dquo; for another patient with relevant similarities. Thus we have come full circle. We do not start with a theoretical perspective and evaluate the necessary therapies, rather we devise individually tailored therapies, seeking to generalise and construct a theory at a later stage. To do this, models should, and must, be mixed so that the entire picture of the patient and the problem is available to the therapist. This is the theme of Social Psychiatry.
How until
can
a
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
166 REFERENCES
Kuhn, T. C. (1962): The Structure of Scientific Revolution; Chicago. Lazare, A. (1973): New Engl. J. Med. 288 (No. 7), 345. Siegler, M., and Osmond, H. (1974): Models of Madness, Models of Medicine; New York; Macmillan.
Williamson, J. D., Robinson, D., and Rowson, S. (1976) in Page No. 162
the
current
volume of this
Downloaded from isp.sagepub.com at NANYANG TECH UNIV LIBRARY on June 20, 2015
Journal,
