Debates and disagreements

Discussions about mental health and psychological well-being often unquestioningly assume that the 'disease model' is the only approach. But this assumption is hotly contested, and passionate debates about the essential nature of psychological distress take place even within psychiatry itself. At one end of the spectrum, many authoritative writers have argued that our psychological well-being can largely be explained in terms of brain functioning. This argument is intimately connected to the idea that problems in brain functioning can be diagnosed as 'mental illnesses', explained in biomedical terms, and treated using medical interventions. The 'disease-model' approach to psychiatry is dependent on a biomedical, reductionist view of human nature. Within modern psychiatry, there are many contrasting perspectives.

Perspective 1 ... 'psychiatry is a medical speciality ... '

It is abundantly clear that many (but not all, by any means) psychiatrists have always been strong proponents of both a biological explanation for mental health problems, and a biological perspective on human behaviour more generally. In 1989, the American Psychiatrist Samuel Guze published a short paper entitled 'Biological psychiatry: is there any other kind?'2 in which he argued that, since all thoughts, all behaviours and all emotions have their origins in the brain, it is to the physical functioning of the brain that we should look for explanations and ideas for interventions. This general principle was developed by Eric Kandel in his well-written and very influential 1998 article; 'A new intellectual framework for psychiatry'.3 For Guze and Kandel, changes in biological functioning are the 'final common pathway' for mental disorder and, indeed, therapy. For Kandel and Guze, all the important factors that affect our mental health do so by causing changes in biological functioning. That includes therapy; if therapy works (Guze and Kandel argue), it works by changing the biology of our brains.

More recently, in 2008, Professor Nick Craddock and 36 colleagues from the UK published an unabashed manifesto for the future of psychiatry - entitled 'a wake-up call for British psychiatry'.4 After acknowledging that improved 'psychosocial care ... is both understandable and welcome', Craddock and colleagues argue that this has been accompanied by the 'creeping devaluation of medicine' in psychiatry. Their argument is that political forces and 'the collusion, or at least the acquiescence, of psychiatrists' has undermined a quintessentially medical approach to psychiatry. They argue that this 'disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and ... medical students'.

Craddock and colleagues' perspective is clear. They state: 'British psychiatry faces an identity crisis. A major contributory factor has been the recent trend to downgrade the importance of the core aspects of medical care. In many instances this has resulted in services that are better suited to delivering non-specific psychosocial support rather than a process of thorough, broad-based diagnostic assessment with formulation of aetiology, diagnosis and prognosis followed by specific treatments.' They continue: ' ... Psychiatry is a medical specialty. We believe that psychiatry should behave like other medical specialties.' This is a precise recapitulation of a medical model of psychiatry. Craddock and colleagues are also refreshingly clear in their professional or political aspirations - this is a precise recapitulation of a medical model of psychiatry.

Unlike Guze and Kandel, Craddock and colleagues advance only implicit, not explicit, arguments about biological aetiology. But those implicit references are clear. They take issue with 'the scepticism of some psychiatrists towards biomedical explanations of illness' and argue that there is ' . .. a very real risk that as the understanding of complex human diseases steadily increases, recent moves away from biomedical approaches to psychiatric illness will further marginalise patients . .. . ' Most tellingly, Craddock and colleagues argue that: 'Major advances in molecular biology and neuroscience over recent years have provided psychiatry with powerful tools that help to delineate the biological systems involved in psychopathology and impairments suffered by patients. We can be optimistic that over the coming years these advances will facilitate the development of diagnostic approaches with improved biological validity and enhanced clinical utility in terms of predicting treatment response. We can expect that completely novel treatments will be developed based on detailed understanding of pathogenesis.'

In other words, Craddock and colleagues suggest that it is risky to be sceptical about biomedical explanations, that moving away from a biomedical approach would harm patients. They confidently expect that molecular biology and neuroscience will help us understand the 'pathogenesis' (the cause or origin of a disease) of mental health problems, confirm the value of 'biomedical explanations of illness' and reinforce the value of a medical psychiatric profession.

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