Philosophies

The underpinning philosophy of traditional, 'disease-model' mental health care is, as my doctor colleague put it, that ' ... ultimately, our job is to treat illnesses'. Services suffer, and in my view often even do harm, because they start from that presumption. This is not helped by the frequent and insistent calls to see mental health in biological, reductionist terms. Such accounts ignore the links between the events in our lives, including in childhood, and our future mental health, suggesting instead that biological processes, pathologies and abnormalities are to blame. This stance was perhaps most acutely revealed in the suggestion made by the person I mentioned earlier who had been asked to review a paper submitted by colleagues of mine exploring the links between childhood sexual abuse and future psychotic experiences. They suggested that the apparent link could actually be a result of the children having a genetic abnormality that not only increased their risk of future psychosis but also actually made them more vulnerable to abuse! This contorted logic serves to minimise the link between childhood trauma and future mental health problems. It serves to exonerate abusers. It minimises the effects of abuse and denies society's responsibility to its victims. And it leaves our efforts to protect children disconnected from our attempts to help those who are suffering the after-effects of abuse either as children or in their later adult lives. Of course not all psychiatrists think like this, especially the colleagues behind what I am terming the 'Bracken Manifesto'. But this way of thinking does endure.

One of its effects is that access to services - as children or adults - is at least partially dependent on meeting diagnostic criteria for a 'disorder' - in other words, being seen as 'mentally ill' in some way. This is especially the case in those countries where insurance companies fund help for people: they will often only do so on the basis of a 'diagnosis'. However, even in the UK access to services is increasingly dependent on such labels. This offends against basic psychological and psychiatric science - we know that events in our childhood and social life affect our emotions and mental health, and it is inappropriate to separate the two. It is also profoundly unhelpful, leaving both children and adults not only dealing with stigmatising labels that suggest that they are defective in some way, but in the invidious position of either accepting these labels or missing out on care. And, vitally, it distracts us from the urgent need for preventative action.

It is unacceptable to see that children are being abused and bullied, and then to wait before offering psychological help until the evidence of harm is sufficient to meet the criteria for a 'mental disorder'. I do not believe that this is what anybody wants. I do not even think that this is in the minds of those misguided individuals who minimise the links between trauma and subsequent mental health problems. And yet this is the consequence of three unfortunate factors: firstly a mental health care system still dominated by a biomedical reductionist ethos and a 'disease-model' mentality, secondly a consequent 'diagnose-treat' approach in which access to services is based upon meeting the criteria for a so-called 'mental illness', and thirdly a separation of mental health services from other social services.

 
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